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Hot Tooth

Endodontic Nontraumatic
Dr shabeel pn

Dental Emergencies
30% of all dental emergencies are
In 90% of painful emergencies, pain is
pulpal or periapical

Pathophysiology of Pain
Pain is a psychobiological phenomenon.
It consists of:
- Perception of pain: influenced by
- Reaction to pain (fear, anxiety):
influenced by drugs and emotions and
contributes to hyperalgesia

Endodontic Pain Management

Anxiety reduction

Effective local anesthetics
Operative techniques

Pharmacologic agents

Differential Diagnosis
Chief Complaint:
Listen to your patient and the patient
will give you the diagnosis
Sir William Osler

- Contents of the root canal?
- Dentist controlled factors?
- Host factors?

History of Chief Complaint

1. What is the nature of the pain?
When did the pain begin?
Pulpal: rapid onset, spontaneous, gets
more intense and more localized
2. What
provokes pain?

3. What drugs have you taken for the
Drug addicts: last pill before the weekend

4. Does the pain awaken you?
5. Where does it hurt, and where
does the pain radiate to?
- Temporal region: premolars and molars
- Ear: mandibular or maxillary (less) molars
- Neck/Shoulder: mandibular molars, heart

Medical and Dental History

SBE prophylaxis
Referred pain
Patient motivation to retain dentition
Restorative treatment plan
Blood pressure and temperature

Clinical Examination
Visual: swelling, sinus tract, aphthous
ulcers, caries, cracks
In the absence of odontogenic source,
look for non-odontogenic etiology

Diagnostic Tests
Pulp Tests:
- Cold (Endo Ice on cotton pellets)
- Heat (impression compound, warm
water with rubber dam)
- Electric pulp test
Periodontal Probing
Periapical Tests:
- Percussion, palpation, ToothSlooth

Radiographic Examination
Parallel Periapical Radiograph
Angled horizontally PA
Follow PDL and lamina dura
Superimposed anatomical structures:
maxillary sinus, mental foramen,
lingual salivary gland depression, IAN
canal (mandibular second molars)


Odontogenic Diagnoses
Dentinal Hypersensitivity
Reversible Pulpitis
Irreversible Pulpitis
Necrotic pulp
Acute Apical Periodontitis
Acute Apical Abscess

Non-odontogenic Pain
No apparent odontogenic etiology
Pain not relieved by local anesthesia
Bilateral pain, multiple teeth
Chronic pain, not responsive to dental
Specific qualities: burning, stabbing,
concurrent with headache
Trigger points, muscles
Stress, head position

Non-Odontogenic Diagnoses
Musculoskeletal: myofascial pain
Neuropathic: trigeminal neuralgia, atypical
odontalgia, glossopharyngeal neuralgia
Neurovascular: migraine, cluster headaches
Inflammatory: allergic or bacterial sinusitis
Systemic: cardiac, herpes zoster, sickle cell
anemia, neoplastic disease
Psychogenic: Munchausens syndrome

Anxiety Reduction
Reflective listening:
- a dialogue of trust between the dentist
and the patient
- cannot be delegated to a staff member
Patients feeling of fear are
Sounds like you have had some
unpleasant experiences in the past

Anxiety Reduction:
Dentists Role
Safe environment, reassurance: I will do whatever can be
done to make your treatment comfortable
Ask patient to summarize
Mix of open and closed questions
Nonverbal Strategies: face the patient at the same chair
level, steady and frequent eye contact, mutual respect
and concern, no promises of painless treatment, frequent
review of accomplishments
Control during treatment: time out, music choice,
nothing will happen that we have not agreed upon

Anxiety Reduction
Office tone: staff attitude
Distraction: music, office dcor, TV
Relaxation techniques: muscular and
mental, deep breathing 2-4 min with
heart rate monitor
Hypnosis (special training) and guided
Referral to a mental health professional

Anxiety Reduction
Conscious sedation: does not treat anxiety, just
facilitate treatment
Benzodiazepines orally: Lorazepam, Triazolam (short
duration, no metabolites), and Diazepam (active
Reversal agent: Flumazenil (Romazicon)
Contraindications and drug interactions ( Triazolam
and protease inhibitors for HIV treatment)
Nitrous oxide
Profound anesthesia is still required
Lindemann et al. J Endod 2008;34:1167

90% of dentists have anesthetic difficulties
Al Reader & John Nusstein Endo topics 2002; 3:14
(17 years of research on endodontic pain anesthesia)

A challenge for inflammed tissue:

Local acidic inflammatory byproducts lower
the pH, so most anesthetic molecules remain
in inactive cationic form
Local prostaglandins and bradykinin can
antagonize local anesthetics

TTX-resistant channels
Sodium channel expression on C fibers
shifts from TTX sensitive to TTX resistant
TTX resistant channels are five times more
resistant to anesthetic (lidocaine)
Bupivacaine found to be more potent
Alternate and supplementary injection sites:
intraosseous, intraligamentory
Anatomic limitations: dense bone, accessory
innervation (mylohyoid nerve branch)

Local Anesthesia
Gow-Gates & Akinosi-Vasirani methods
- effective in 89%
Parente & Welte, 1998

- 2% lido with epi 1:100,000 increased heart

rate in 67% of patients to 97 bpm
Replogle & Reader, 1999

Mandibular Anesthesia
IANB: most failures; 25% of accurate blocks
fail; central core theory
EPT is predictable for pulpal anesthesia
Lip sign is not predictable, but lack of it (5%)
predicts failure; requires re-administration
Noncontinuous anesthesia 12-20% man
Slow onset 19-27% after 15min; 8% after
Duration 2.5 h

Inferior Alveolar Nerve Block

Double volume (2 cartridges) of 2%
lidocaine with epinephrine does not
increase the incidence of pulpal
Increase epinephrine concentration to
1:50,000: no advantage
3% mepivacaine is as effective as 2%
lidocaine with 1:100,000 epinephrine

Articaine: as effective, but no advantage
Contraindications: Sulfa allergy
Mandibular buccal infiltration with 4%
articane is more effective that 2% lidocaine
with epinephrine
Kanaa et al. J Endod (32)4:296
4% Articaine with epinephrine 1:200,000

Long-acting anesthetics:
Bupivacaine (Marcaine): 4 hours of lip
numbness, ask patient
0.5% Ropivacaine with 1:200,000
epinephrine (Naropin): lower potential
for CNS and cardiovascular toxic

Mandibular Teeth
Infiltration with 2% lidocaine and
epinephrine: no advantage
Gow-Gates: no advantage in
anesthesia, less possibility for the
intravascular injection
Akinosi-Vasirani technique: trismus
Incisive nerve block at mental foramen:
premolar teeth

Needle Deflection and STA

Bi-directional needle rotation technique
Computer-assisted Wand or STA
(Single Tooth Anesthesia):
no significant differences in success
for IANB
Pain perception: less painful with STA

Supplemental Injections
Intraligamentory Anesthesia
STA (CompuDent):
single tooth anesthesia
2% lidocaine with
epinephrine 1:100,000 or
4% articaine
with epinephrine 1:200,000

Intraosseous Injection
Key to success: deposition into the
cancellous space; 10% constricted spaces
In 0-48% transient moderate to severe pain
on perforation and deposition of anesthetic
Perforator breakage
Optimal site: DISTAL to the problematic tooth
Except second molars: MESIAL to the tooth
Immediate onset

Intraosseous Anesthesia
Irreversible pulpitis: IANB 44-81% failures
Mandibular intraosseous anesthesia of 1.8 ml
of 2% lidocaine with 1:100,000 epinephrine
gives 91% success (Nusstein et al.)
Transient increase in heart rate (4 min)
Supplemental 1.8 ml 3% mepivacaine
produces 80% success; repeated injection
increases success to 98%; no increase in
heart rate

Intraosseous Anesthesia
Long-acting anesthetic are not longacting with this technique and have
cardiotoxic effects: no advantage
Large volumes: overdose reactions
Should not be considered intravascular
Postoperative discomfort 2-15%
Less than 5% swelling/exudate on
perforation site; may take weeks to
heal; bone overheating

Intrapulpal Anesthesia
5-10% of irreversible pulpitis cases do
not respond to supplemental
Moderately to severe painful
Short (20 min)
Pulp must be exposed
Predictable under back-pressure

Clinical Management
of Endodontic Anesthesia
Irreversible pulpitis:
IANB for mandibular teeth, observe lip sign,
inform patient, intraosseous anesthesia 1.8
ml 3% mepivacaine; apply rubber dam; if
painful, administer intraosseously another
carpule of 3% mepivacaine
Use #2 sharp round bur to make a channel
into the pulp chamber. If pulp is entered and
painful, proceed with intrapulpal anesthesia

Irreversible Pulpitis
Maxillary Teeth
Double the initial anesthetic dose for
the buccal infiltration
PSA for molars
Small amount 0.5 ml palatally for the
clamp and palatal canals; avoid 1:50,000
Less failures, but can occur
Intraosseous anesthesia
Repeat infiltration during the treatment

Symptomatic Teeth with Pulpal Necrosis

and Periapical Radiolucencies
Mandible: inferior alveolar nerve block
Maxilla: infiltration or block
Swelling: injection on either side
SLOWLY access
DO NOT use intraosseous, periodontal
ligament, or intrapulpal injections:
painful and ineffective, introduce
bacteria periapically

Intraoperative Management
Combined Approach
Pharmacological (not drugs alone)
Pulpotomy: reduces pain in 90% of patients
Incision for drainage, trephination/apical
Occlusal reduction
Informed Consent Form


Case of acute pain of pulpal origin, NO periapical

pathology, and not enough time for pulpectomy
Goal: to remove coronal pulp; place rubber dam,
use slow speed round bur to the canal orifice
Bleeding is managed with sterile cotton pellet
With or without dressing; cavity should be sealed
High level of success: alteration of pulpal
hemodynamics, reduction of interstitial fluid
pressure and inflammatory mediator

Pulpotomy vs. Partial

Pulpotomy is preferable when there is
lack of time for complete pulpectomy
with accurate canal length
Partial pulpectomy may result in a
profuse hemorrhage and more
postoperative pain; traumatizes already
inflammed tissue

Reduction of inflammatory mediators
levels and interstitial tissue pressure to
relieve peripheral terminals of
With/without I & D provides predictable
pain reduction in endodontic

Intracanal medications
Calcium hydroxide (Ultracal): effective
antibacterial, not analgesic
Leave tooth open or closed? Closed!
Open tooth: additional bacterial
contamination, foreign body reaction,
blockage with food, and complications

Incision & Drainage Rationale

Decreases number of bacteria
Reduces tissue pressure, which alleviates
pain & trismus and improves circulation
Prevents spread of infection
Alters oxidation-reduction potential
Accelerates healing
Trephination: #3 spreader in patients with
pain, radiolucencies, and no swelling
Results in more pain, routinely not justified
Moss et al. 1996

Irreversible Pulpitis
with Periapical Inflammation
PULPECTOMY: anterior teeth; posterior
teeth on all roots
Occlusal reduction
Rubber dam
Instrumentation to a size #25 minimum
Irrigation with 2.6 % or 5.25% NaOCl

Necrotic Pulp, No Swelling

Complete debridement
Estimated working length (1 mm short
of anatomical length)
Instrument crown-down to a size #25
minimum or 3 sizes larger than the first
file that binds
Copious irrigation with 2.6-5.25%
Calcium hydroxide intracanal dressing

Necrotic Pulp, Localized

Complete debridement: determine working
length for all canals, rotary Ni-Ti files
If drainage through the tooth is obtained,
I & D is optional; antibiotic is not indicated
Do NOT leave tooth open
Fluctuation: anesthesia around it and I & D
Warm saline rinses for 48 h
No fluctuation: I & D is contraindicated

Diffuse extraoral or intraoral swelling
Rapid spread into spaces
Systemic signs of infection
Lymphadenopathy, fever
Difficulty swallowing, mouth opening
Sublingual and palatal aspects
Referral to an oral surgeon or ER

Long-acting Anesthetics
Bupivacaine, ropivacaine: blocks up to
Block the activation of unmyelinated C
nociceptors (anesthesia)
Decrease potential for central

Postoperative management
Non-narcotic analgesics
Pretreatment is effective for post
treatment pain:
Ibuprofen (800mg) (Advil Liquid Gel) or
Flurbiprofen (100mg)
Patients who cannot tolerate NSAIDs:
GI disorders, active asthma, hypertension
(renal effects of NSAIDs or interactions with
anti-HTN drugs):
Acetaminophen (1000mg) (also, COX-3
enzyme inhibition)

NSAIDs: Mechanism of Action

for Irreversible Pulpitis
Reduction of pulpal levels of the
inflammatory mediator PGE-2 causes:
- Decrease in pulpal nociceptor
- Decrease of a prostanoid-induced
stimulation of TTX-resistant sodium
channel activity
- Decrease in resistance to local

Ibuprofen and
Combination may be more effective
than ibuprofen alone for the
management of postoperative
endodontic pain
Menhinick et al. 2004
Ibuprofen 400 mg and Acetaminophen
1000 mg
Timing: Q6-8 h for the first few days

Patients taking 30 mg of codeine have
as much analgesia as with placebo
Troullis et al. 1986

60 mg of codeine (2 Tylenol-3) produce

significantly more analgesia than
placebo, but less that 650 mg of
aspirin, or 600 mg acetaminophen

The Most Effective Analgesics

Combination of flurbiprofen and
Combination of preoperative and
postoperative flurbiprofen
Doroshak et al. J Endod 1999;25:660

Tramadol hydrochloride: an opioid

agonist and a reuptake inhibitor of
serotonin and norepinephrine

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

NSAIDs Drug Interactions

Anticoagulants: increased prothrombin time
or bleeding time
ACE inhibitors, Beta Blockers, Thiazide:
reduced antihypertensive effects
Cyclosporine: increased risk of
Lithium: increased serum levels of lithium
Sympathomimetics: increased blood

Flexible Prescription Plan

Goal: to obtain maximal analgesic benefits
with minimal side effects
First, maximize the dose of non-narcotics
before prescribing narcotics
If patient still has pain:
1. NSAIDs with acetaminophen over a short
period of time
2. NSAIDs with opioid or with
Flurbiprofen with Tramadol (Holstein et al.)

Flexible Analgesic Plan

Aspirin-like Drugs are Indicated
Mild pain: 200-400 mg ibuprofen or 650
mg aspirin
Moderate: 600-800 mg ibuprofen plus
combo analgesic = 60 mg codeine
Severe: 600-800 mg ibuprofen plus
combo analgesic = 10 mg oxycodone

Aspirin-like Drugs are

Mild pain: 600-1000 mg acetaminophen
Moderate: 600-1000 mg acetaminophen
and opiate = 60 mg codeine
Severe: 1000 mg acetaminophen and
opiate = 1 mg oxycodone

Indications for Antibiotic

Systemic involvement or fascial space
Compromised host resistance
Inadequate surgical drainage
Select antibiotic with anaerobic spectrum or
antibiotic-sensitivity charts (C & S available)
Contraindicated as a preventive measure
Use a larger dose for a shorter period of time
Pseudomembranous colitis

Penicillin V
When Gram stain and C & S results are
not available, PCN is antibiotic of
Loading dose: 1-2 g, then 500 mg qid
for 7-10 days
Metronidazole: 250 mg qid 7-10 days
Used in conjunction with Penicillin V

Loading dose: 300 mg
150-300 mg qid for 7-10 days
Cephalexin (Keflex)
Loading dose: 1 g
500 mg qid for 7-10 days

Multiple sites of action
Reduce pulpal concentrations of PGE2
Reduction of bradikinin (proinflammatory)
Produce vasocortin (decreases edema)
Inhibit nitric oxide synthase (amplifier of
inflammatory response)
Single large dose or short course up to 1
week is harmless
Contraindications: systemic fungal
infections, renal insufficiency, ulcerative
colitis, diabetes, others

Intracanal Ledermix (triamcinolone and
tetracycline derivative) or dexamethasone 0.1
ml per canal: significantly less pain
Liesenger et al. J Endod 1993:19:35
Symptomatic necrotic teeth; pulpectomy with
intraosseous methylprednisolone (DepoMedrol 40 mg/ml): significantly less pain
Bramy et al.

Antibiotics are NOT routinely required
in conjuction to prevent infection
secondary to reduced inflammation in
healthy patient
Steroids are effective as an adjunct to
but not replacement for appropriate
endodontic treatment
Systemic steroids are highly effective
for patients with moderate/severe
preoperative pain and pulpal necrosis
with periapical radiolucency

Causes of Flare-Ups
Overinstrumentation, overmedication
Debris extruded into periapical tissue
Incomplete debridement or missed canal
Exacerbation of chronic apical periodontitis
Over-irrigation, NaOCl accident
Hyperocclusion: occlusal reduction benefit
symptomatic patients (vital pulp, no PARL)
Root fracture
Wrong tooth
Air emphysema: air syringe into root canal; Stropko
Pasteur effect (overgrowth of facultative anaerobes)
Seltzer & Naidrof J Endod 1985

Predictors of Post-Endo Pain

Preoperative pain or swelling
Walton and Fouad 1992

Preoperative pain and anxiety

Torabinejad 1994

Preoperative pain, necrotic, PARL,

Genet 1987

Treatment of Flare-Ups
Psychological (reassurance), localized
operative, and pharmacological
Necrotic pulp with swelling: open, re-debride,
I & D, adjust occlusion
Antibiotics: rapid increase S & S, anatomical
danger zone, disease/drug that compromises
immune status, systemic involvement (LAD,
fever, malaise)
Steroids: effective for lower levels of pain;
single dose dexamethasone 4-6 mg

Case #1
No definitive treatment plan until the
diagnosis is confirmed

Case #2

Irreversible Pulpitis with Acute Apical

Tooth #18

Case #2
Irreversible Pulpitis with Acute Apical
Preoperative: NSAID (ibuprofen 800 mg or
flurbiprofen 100 mg) possibly with tramadol
(50mg) or acetaminophen (500mg)
augmentation for the next 2 days
IANB; intraosseous 3% mepivacaine distally
Occlusal reduction
Endo: #2 round bur access into the chamber;
intrapulpal anesthesia; complete pulpectomy

Case #3
Necrotic Pulp with Acute Apical

Tooth #18

Case #3
Necrotic Pulp with Acute Apical

Preoperative: NSAIDs or acetaminophen

IANB; avoid intraosseous in necrotic teeth
and PARLs or distal to the adjacent tooth
(Reader, Nusstein)
Complete pulpectomy; avoid intrapulpal
Postoperative: flexible analgesic plan
Occlusal reduction?
Antibiotics are not required and do not
reduce postoperative pain

Case #4Postendodontic Flare-Up

Repeat vitality tests (missed canals)

Contributing risk factors: female, necrotic
pulp, acute apical periodontitis
Patient did not respond to NSAIDs: pain is
due to non-prostaglandin mediators

Case #4
Reassurance in a favorable prognosis
Effective local anesthesia: infiltration or
block with bupivacaine
Steroid injection: dexamethasone 4-6mg
(immune-mediated hypersensitivity reaction
Daily contact
Postoperative analgesics: flurbiprofen 100
mg tid with tramadol 50-100 mg q6h
Endodontically: conservative care, may or
may not remove the fill

Accurate diagnosis
Successful anesthesia
Timely and effective