Endodontic pain Lec 3.docx

Endodontic Pain: CLINICAL FACTORS Lecture 3 Paul A. Rosenberg, DDS Diplomate American Board of Endodonti cs Professor Department of Endodonti cs NYUCD [email protected] 12/8/2023 ENDODONTIC PAIN... Part 3 Review ANALGESIC STRATEGIES FOR PAIN PREVENTION AND MANAGEMENT HYDROCODONE & IBUPROFEN / A...

Endodontic Pain: CLINICAL FACTORS Lecture 3 Paul A. Rosenberg, DDS Diplomate American Board of Endodonti cs Professor Department of Endodonti cs NYUCD [email protected] 12/8/2023 ENDODONTIC PAIN... Part 3 Review ANALGESIC STRATEGIES FOR PAIN PREVENTION AND MANAGEMENT HYDROCODONE & IBUPROFEN / ACETAMINOPHEN (Vicodin) OTC ASPIRIN ACETAMINOPHEN / IBUPROFEN & CODEINE MODERATE PAIN SEVERE PAIN LONG ACTING LOCAL * ACETAMINOPHEN * IBUPROFEN NAPROXEN MILD PAIN NSAID ANESTHETIC NSAID PREEMPTIVE MEASURES INTRAOPERATIVE PAIN ONSET Modified from R.Dionne 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. 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 that DO NOT EXCEED 3 GRAMS PER DAY, ASSUMING A HEALTHY LIVER BEWARE OF OTHER MEDICATIONS CONTAINING ACETAMINOPHEN 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.” “…minimize exposure by using the lowest effective dose for the shortest period of time.” Current Advice 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? Current Research A randomised,five-parallel-group- placebo 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 Analgesics 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/codeine15mg 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. Fouad AF Are antibiotics effective for Endodontic pain ? An evidenced-based review Endodontic Topics 2002,52-66 Can systemically administered antibiotics reach pulpal and periradicular tissues in therapeutic concentrations ? Studies show that antibiotics can permeate vital pulpal/periapical tissues in hours but permeation of empty pulp space may take days presumably by diffusion. but in a non vital case… Because of the lack of circulation, systemically administered antibiotics are not effective against a reservoir of microorganisms within an infected root canal system. A minimum inhibitory concentration of an antibiotic may not reach an anatomic space filled with purulence and edematous fluid because of poor circulation and the diffusion gradient. Antibiotics do not relieve pain due to irreversible pulpitis Are pre operative antibiotics an effective strategy? Prospective randomized, double - blind, placebo controlled study. Prophylactic dose of amoxicillin before endodontic treatment of asymptomatic, necrotic teeth had no effect on endodontic flare-ups. Pain without signs or symptoms of infection Symptomatic irreversible pulpitis Symptomatic(chronic apical abscess)periodontitis Teeth with necrotic pulps and a radiolucency Teeth with a sinus tract Localized fluctuant swellings Fever >100 F, malaise, lymphadenopathy, trismus Increased swelling, cellulitis , Continue to instrument/irrigate Terminology Flare- ups… Definition of an Endodontic Flare-up Classic Research Walton R and Fouad A, 1992 Anxiety …well documented that a high level of fear and anxiety can have a marked effect on a patient’s response to treatment. … multivariate analysis of the effectiveness of local anesthesia in pediatric patients indicated that anxiety is the strongest predictor of poor pain control. ( Nakai Y. JADA 2000) Number of Visits A number of studies (Roane JB 1983) have demonstrated that less post operative pain results from a single visit approach Re-treatment Cases In most studies re-treatment cases have had a significantly higher incidence of flare-ups. Trope (1991) found an extremely high incidence of flare-ups(13.6%) in retreatment cases with apical periodontitis. 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) What you do with your hands matters Rosenberg PA, Babick PJ, Schertzer L and Leung A. The effect of occlusal reduction on pain after endodontic instrumentation J Endod 1998; 24:492-96. Preoperative Conditions Pulp vitality Percussion sensitivity Periradicular radiolucency Pre operative pain Swelling Stoma History of bruxism What we did… Clinical Procedure Occlusal reduction Simulated reduction Control The tooth involved felt normal or slightly sensitive. “Pain killers” were not necessary. The tooth involved caused inconvenience and/or pain, but neither work nor sleep were disturbed. With the use of “pain killers”, the pain could be held under control. The pain disturbed normal work or sleep. Pain killers had little or no effect. Statistical Evaluation 80 Vital Pulp (n=66) p= <0.01 70 Total 60 Reduction 50 Simulated 40 Reduction 30 Control 20 10 0% No Pain Moderate Pain Severe Pain Patient response, 48 hours 80 Non Vital Pulp (n=51) p= 0.58 70 Total 60 Reduction 50 Simulated 40 Reduction 30 Control 20 10 0% No Pain Moderate Pain Severe Pain Patient response, 48 hours Absence of a Periradicular Radiolucency (n=79) p= <0.01 70 60 Total Reduction 50 3 40 Simulated Reduction 30 20 Control 10 0% No Pain Moderate Pain Severe Pain Patient response, 48 hours 80 Percussion Sensitive (n = 57 ) p= <0.01 70 Total 60 Reduction 50 Simulated 40 Reduction 30 20 1 Control 10 0% No Pain Moderate Pain Severe Pain Patient response, 48 hours 70 Presence of Preoperative Pain (n= 53 ) p= <0.05 60 Total 50 Reduction 40 Simulated Reduction 30 20 Control 10 %0 No Pain Moderate Pain Severe Pain Patient response, 48 hours Pre operative pain Pulp vitality Percussion sensitivity Absence of periradicular radiolucency How many teeth in our study exhibited all four significant conditions ? How did those teeth respond to the different occlusal treatments ? n=27 8%0 70 Teeth with all 4 indicators (n=27) p<0.01 Total 60 Reduction 50 Simulated 40 Reduction 30 Control 20 10 0 No Pain Moderate Pain Severe Pain Essentially a problem of managing inflamed tissue Usually iatrogenic Incorrect Measurement or failure to maintain measurement Over instrumentation Over filling Occlusion Bacteria or bacterial by products pushed into the apical tissues from the canal system. Incorrect measurement or failure to maintain measurement Over instrumentation Over filling Pulpotomy Pulpectomy / Reinstrumentation Occlusal adjustment Incision and drainage (Non vital only) Trephination (not recommended) Medication Non Vital Exacerbations : an imbalance between host and parasite * Gram (-) Rods “…all I did was open the tooth” Inflammatory responses are complex and consist of diverse elements including immediate-type responses and non-specific immune responses. Granuloma THE PRIMARY IRRITANT IS BACTERIA l. Also involved, are mediators of inflammatory and immune reactions. Represents localization of an infectious process Represents the host’s inability to localize an infectious process Localization of an Infectious Process DRAINAGE CANAL INCISION AND DRAINAGE REDUCTION OF PERIAPICAL PRESSURE EVACUATION OF PUS This patient’s inflammatory and immune responses are Incision and Drainage Courtesy of Dr. Leigh Busch Incision and Drainage New insights Thank You CASE HISTORY What do you see clinically and on the radiograph ? ACCESS What is happening? IRRIGATION IMMEDIATELY AFTER IRRIGATION …TEN DAYS LATER IRRIGATION GUIDELINES NEVER WEDGE THE IRRIGATING NEEDLE IN THE CANAL INJECT SLOWLY BEWARE OF THE APEX LIFE THREATENING EMERGENCIES THREATS TO THE DENTIST PUNCTURE WOUNDS EYE TRAUMA PROCEDURAL ERRORS BROKEN INSTRUMENTS LEDGED CANALS PERFORATIONS PREVENTING PROCEDURAL ERRORS PREOPERATIVELY REVIEW RADIOGRAPHS LOOK FOR CURVATURES AND CALIFICATION MAINTAIN MEASUREMENT TO AVOID LEDGED CANALS AND PERFRORATIONS FINESSE NOT FORCE SERIOUS PATIENT COMPLICATION ASPIRATION OF AN INSTRUMENT SWALLOWING AN INSTRUMENT CELLULITIS ALWAYS USE RUBBER DAM Important clue: Words used to describe pain Odontogenic Non-odontogeni Throbbing Burning Sharp Tingling Dull ache Electric Diagnostic Clue The site of perceived pain may differ from the site of nociceptor activation Reminder: Palpate Muscles Courtesy Dr. A. Sigurdss Herpes Zoster Thank You WHAT IS THE ROLE OF OCCLUSION IN EXACERBATIONS ??? ROSENBERG PA, BABICK PJ, SCHERTZER L and LEUNG A. THE EFFECT OF OCCLUSAL REDUCTION ON PAIN AFTER ENDODONTIC INSTRUMENTATION. J. ENDOD 1998; 24: 492- 96. RECORDED… PREOPERATIVE CONDITIONS PULP VITALITY PERCUSSION SENSITIVITY PERIRADICULAR RADIOLUCENCY PREOPERATIVE PAIN SWELLING STOMA HISTORY OF BRUXISM WHAT WE DID… CLINICAL PROCEDURE OCCLUSAL REDUCTION SIMULATED REDUCTION CONTROL QUESTIONNAIRE Which of the following statements regarding your pain is true ? No pain- The tooth involved felt normal or slightly sensitive. Pain killers were not necessary. Moderate pain- The tooth involved caused inconvenience and/or pain, but neither work nor sleep were disturbed. With the use of pain killers, the pain could be held under control. Severe pain- The pain disturbed normal work or sleep. Pain killers had little or no effect. STATISTICAL EVALUATION VITAL PULP (n=66) p= <0.01 80 70 60 % 50 40 30 20 10 0 No Pain Moderate Pain Severe Pain PATIENT RESPONSE, 48 HOURS NON VITAL PULP (n=51) p= 0.58 80 70 60 % 50 40 30 20 10 70 71.4 52.9 28.6 20 35.3 10 11.8 Total Reduction Simulated Reduction Control 0 0 No Pain Moderate Pain Severe Pain PATIENT RESPONSE, 48 HOURS ABSENCE OF A PERIRADICULAR RADIOLUCENCY (n=79) p= <0.01 80 70 60 % 50 40 30 20 10 0 No Pain Moderate Pain Severe Pain PATIENT RESPONSE, 48 HOURS PERCUSSION SENSITIVE (n = 57 ) p= <0.01 80 70 60 % 50 40 30 20 10 0 No Pain Moderate Pain Severe Pain PATIENT RESPONSE, 48 HOURS PRESENCE OF PREOPERATIVE PAIN (n= 53 ) p= <0.05 70 60 50 % 40 30 20 10 0 No Pain Moderate Pain Severe Pain PATIENT RESPONSE, 48 HOURS SIGNIFICANT CONDITIONS PREOPERATIVE PAIN PULP VITALITY PERCUSSION SENSITIVITY ABSENCE OF PERIRADICULAR RADIOLUCENCY HOW MANY TEETH IN OUR STUDY EXHIBITED ALL FOUR SIGNIFICANT CONDITIONS ? HOW DID THOSE TEETH RESPOND TO THE DIFFERENT OCCLUSAL TREATMENTS ? Presence of all four significant preoperative conditions (n=27): preoperative pain, pulp vitality, percussion sensitivity and absence of a periradicular lesion . ( p<0.01) 80 70 60 % 50 40 30 20 10 0 No Pain Moderate Pain Severe Pain CONCLUSION OCCLUSAL REDUCTION SHOULD AID IN THE PREVENTION OF PAIN FOLLOWING ENDODONTIC INSTRUMENTATION IN THOSE PATIENTS WHOSE TEETH EXHIBIT ONE OR MORE OF THE FOLLOWING: CONDITIONS PREOPERATIVE PAIN PULP VITALITY PERCUSSION SENSITIVITY ABSENCE OF A PERIRADICULAR LESION