#DEN4001
#D4/S1/W7
#Paediatrics
#Endo

Local Anaesthetics for Endodontics

LA Preop assessment

• level of anxiety
• previous history and experience
• cooperativity
• mouth opening
• gag reflex
• overall physical health
• appropriateness for other forms of sedation such as inhalation or IV

Assessment for IV sedation

• previous history
• drug abuse
• general health
• mallampati score
• children - unpredictable
• sleep apnoea (thyromental distance)
  • 
• severe anxiety phobia
• cant open for long periods
• cant sit for long periods
• cant handle rubber dam
• severe gag reflex
  Mallampati score
  

Psychological management

• perceive all symptoms and complaints as real
• show support, listening actively, express empathy, being non-judgemental, eye contact
• calm and confident
• positive attitude
• patient should be informed about what to expect
• ask why they are anxious

Endodontic therapeutics

• rationale -> reduction of chemical mediators that activate or sensitise nociceptors
• analgesics
  • non narcotic NSAID, paracetamol (nuromol, nurofen, voltaren, maxigesic, advil)
  • opoids
• steroids (Dexamethasone 4mg bid x 4 tablets) post op
• anxiolytics

Pre medication

• can improve IANB efficacy
• ibuprofen, nurofen, diclofenac, voltaren, dexamethasone

Pre op anxiolytics

• triazolam 0.25mg (halcion)
  • no hangover effect compared to diazepam or temazepam, bc only 3hour halflife
• diazepam 5mg,
• tempazepam 5mg

Inhalation sedation

• nitrous oxide
  • increased release of endorphins
  • blocks pain reception
  • state of euphoria
• penthrox
  • green whistle
  • short acting, hard to use but can ease anxiety

Cognitive behavioural therapy

• environment affects the mood
  • music
  • television
  • aromatherapy
  • relaxing herbal tea
  • hyponosis
  • distraction techniques
• take time
• build rapport and trust

Dr Mehdi Anaesthetic cream

• prilocaine 4%, tetracaine 10%, lignocaine 4%
  • hydrophilic base
  • 3 active ingredients
  • better penetration
  • need a script however, and can cause some throat discomfort

Painless injection

• dental vibe significantly lowered self reported pain
• gate theory of pain
  • pain and pressure go through same action potential pathway
  • e.g. rubbing wound less perception of pain
• the wand
  • slow injection via computer

Which LA to use

• articaine
  • better bone penetration ability
  • better lipid solubility and diffusion compared with lido caine
  • onsent of anaesthesia is much faster, just as effective in IANB
  • however, no clear evidence that it provides better paraesthesia
• bupivicaine - long acting
• lignocaine - short onset
• must have adrenaline or felypressin
• no stat sign difference between all LA (Allegretti et al 2016 and Kung et al 2015)

Definitive treatment

• pulpotomy vs pulpectomy
• complete debridement (cleaning and shaping)
  • only if time permits
• pulp necrosis -> managed by complete removal of pulp -> WL radiograph
• due to time constraints -> pulpotomy if pulp inflamed
• most of the axons are in the pulp chamber, therefore pulpotomy can cut off the detector system
  • AKA peripheral axonomy
  • for vital pulp cases
  • 
• Pulpotomy reliably reduces pain and has less incidence of post op pain vs partial pulpectomy
• partial pulpectomy can lacerate, shred and further traumatise the inflamed tissue

La Problems

• la is less effective when administeered to patients with inflamed tissues
• clinical studies - single IANB ineffective in 25-80% of patients with irreversible pulpitis
• preoperative pain and mandibular posterior teeth are most predictive factors for failure of anaesthesia
• ionised form less available in inflamed tissue, which means reduces sodium channel blockage -> failure to anaesthetise
• pulpitis 8x higher failure rate
• even when A delta is anaesthetised, c fibres can carry
• hargreaves and keiser 2002,

Why isnt LA working

• operator inexperience
• anatomical factors
• bone density
• volume or concentration of anesthetic
• inflammation less ionised LA available
• inflamed nerves = lower excitability thershold
• Tetrodotoxin resistant (TTXr) sodium channels on C fibres (more resistant to LA, can last in situations even when blood vessels r gone/ can live in hypoxic situation)
• Increased expression of TRPV1 and TRPV2 and hyperalgesia
• psychological factors

Inflamed pulp what to do

• have a plan of action
• anaesthetise logically (follow landmarks)
• suggestions
  • increase volume
  • gow gates block (avoid inflammation/ anaesthetise up the nerve)
  • supplemental injections
  • time

Testing for efficacy of IANB

• gradual pulp test El sayad and Gaballah 2021
• after block
• wait 5 minutes and is lip numb
• cold spray test buccal, lingual and occlusal surfaces
• if +ve to cold
  • gow gates and or other supplemental injections

Gow gates mandibular block

• true mandibular block
• auriculo temporal nerve
• buccal nerve
• inferior alveolar nerve
• lingual nerve
• mylohyoid nerve (innervates 20% of posterior mandibular molars), usually branches a lot higher)
• 
• 
  • commisure of lip, coronoid process notch
• 
  • posterior to MP cusp of 2nd molar
• technique
  • hit the anterior aspect of the condyle
  • needle parallel to inferior border of mandible
  • aim at tragal notch of the ear
  • MP cusp of 2nd molar
  • aim from premolar enter tissue, swing to closer to the midline/ipsilateral
  • progress until bone, retract, aspirate, inject
  • usually still need long buccal

Intraosseous and intraseptal approaches

• highly effective
• no lip or tongue anaesthesia
• use of special perforator
• very unlikely to ever use

Intraligamentary approach

• more for exo than endo, but sometimes its the option for maxillary facial swelling with cellulitis
• supplemental injection into PDL
• always interproximal, never facial lingual or furcal
• supported using thumb and forefinger, much use a lot of pressure
• mesial then distal
• usually only for unique situation

Intrapulpal

• bend needle, direct pressure
• very painful, need to up the nitrous
• may need to do in each canal separately

Endodonitc surgery

• mix Rexocaine with artocaine
  • rexocaine - lidocaine with 1:80k adrenaline
• rapid onsent, profound anaesthesia, prolonged action, low toxicity, high diffusion rate, higher epinephrine conc
• tissue blanching = haemostasis

Endodontics in medically compromised patients

Why

• aging population
• people live with conditions, take multiple medications

examination

• higher prevalence of endo pathosis in diabetes
• pulp of diabetics
  • limited collateral circulation
  • impaired immune response
  • higher risk of becoming infected
• moderate risk of associated of cardio disease, diabetes
• smoking
  • higher prevalence of endo pathosis
  • periapical lesions
  • incidence of root canal treatment
• traceable pulp chamber, canals
• calcification
  • lifetime cumulative irritation to pulp
  • sickle cell anaemia enamel hypomin, calcified canals
  • patients receiving substantial doses of corticosteroids after renal transplantation
  • pulp stone - cardiovascular disease and those on statins
• radiotherapy in head and neck
  • progressive decrease in pulp vitality testing and EPT at 12months
  • more false negative and less reliable pulp testing

Diagnosis

• herpes zoster
  • post herpetic neuralgia mimics endo pain
  • can also induce spontaneous endo pathosis
  • Dx tests, build coherent narrative
• use probability concept, strong or weak evidence from test, findings and history

Case discussion with patients

• hypertension can reduce survival rates
  • diabetes and or hypertension reduced survival in 10 years
  • hypertension hazard ratio 1.18
  • diabetes hazard ratio 1.29
  • stat sig but small seffect sizes
  • perio confounding factors??
• radiotherapy pt
  • limited mouth opening
  • fibrotic tissues
  • referral
  • dry mouth -> recurrent caries, refinfection, retreatment, need to address dry mouth
• smoking
  • increased incidence of pain and swelling and post surg infection
• allergy
  • flare up
  • hypersensitivity to GP, LA, NaOCl and Ni should be considered
• MRONJ
  • recent dentoalveolar trauma
  • duration of bisphosphonate
  • oral >3 years with a linear increase therafter
  • IV mean 9 month after
  • potency, oral lower risk, IV higher risk
  • increased risk with CS or chemotherapy
  • denosumab equally problematic as IV bisphosphonates

Treatment

• MRONJ
  • clamps shoudl be carefulyl plafced to avoid injury to soft tissue
  • rubber end on clamp?
• on anticoagulants
  • INR needs to be 2-3
  • anticoagulant therapy should not be altered, condition that they are prescribed for is much more critical than dental work
  • INR up to 4 is okay for no LA or LA infil
  • INR up to 2.5 if IANB, bone removal, periradicular surgery
  • check INR within 24 hours prior to procedure
    • if much higher than normal, even if <4, postpone and refer to clinician maintaining anticoagulant therapy
• No NSAIDS for
  • antithrombotic therapy
  • previous history of MI
  • renal disease
  • severe asthma
• drug interactions
  • broad spectrum antibiotics interfere with oral contraceptives, women advised not to rely on pills alone for 1mo after end of antibiotic course
  • antibiotics interfere with warfarin, consult medical people

Monitoring

• immunocompromised pt may have less favourable endo treatment outcome, may be due to healing impairment
• HIV/AIDS
  • no impact on flare up rate or outcome (1y period)
• diabetics
  • treatment outcome generally not different
  • but with preop lesions diabetics lower healing rate
• radiotherapy
  • healing rate similar to normal cases, but small sample size
• oral bisphosphonate
  • no effect treatment outcome

Medical flip flopping

• statistical significance vs small effect sizes
• early demonstrable tx effectiveness
• term for when something is good, then it is bad 10 years later, then it is good again (eggs, coffee etc.)

Endodontic emergency

endo emergency

• situation where a patient experiences pain due to inflammation of pulp or peri radicular tissues, pain resulting from infection in RC system or peri radicular, trauma is also included

when do they occur

• prior to endo treatment
  • teeth that haven't undergone endo yet
• during endo treatment
  • retreat or teeth being treated across multiple appointments, referred to as flare up
• after endo treatment
  • postop pain
  • reinfection after treatment

How to manage them

• diagnosis
• definitive dental treatmnet
• drugs

Pain/Emergency cases

• triaging - emergency vs urgency
  • emergency - risk of swelling or infection, might end up in hospital
  • urgent - pt wants it soon
• irreverisble pulpitis
  • severe pain, constant, throbbing, dully, severe agonising pain
• symptomatic apical periodontitis
  • pain on pressure
• AAA
• crown or crown root fractures
• root fracture
• luxation injuries
• avulsion

Pain

• odontogenic pain
  • activation of pulpal and periradicular nociceptors
  • hyperalgesia
    • spontaneous pain
    • allodynia - reduce pain threshold
    • increased response to painful stimuli
• non odontogenic
  

Burning sensation

• cancer, tumour, neuralgia

Diagnosis

• reproduce chief complain
• patients in pain -> confused
• exaggerated or even inaccurate response
• do not rush diagnosis
• in a true endodontic emergency only, one tooth is symptomatic usually
• tests
  • thermal test
  • EPT
  • percussion
  • palpation
  • transillumination
  • site specific testing e.g. frac finder
  • test cavity
  • selective anaesthesia
  • radioggraphic
• dual diagnosis, pulpal and periradicular

Importance of WL patency and glide path

• glide path
  • continuous path along the extent of the root canal using small diameter tapered instruments
  • apical lesions = essential for gaining patency prior to instrumentation
  • clean apiucal foramen, better irrigant delivery to apical third

Medicaments

• leftover tissue may produce extreme postop pain
• odontopaste good for antipain
• CaOH best antibacterial

Temporisation

• cavit and GIC double seal
• minimum 4mm
• always take postop

Endo band

• interproximal stripper
• must be best size/fit

Fluctuant swelling

• debridement drainage
• always incise and drain

Antibiotics

Occlusal reduction

• 
• works after 3 days, usually inflammation must reduce first

Periop complications

Irrigation

• forceful injection of irrigating solution
• irrigating needle wedged into root canal when irrigating
• open apex
• prevention
  • needle should never bind under walls
  • never under pressure
  • gentle oscillating motion
  • avoid open apices
  • side venting needles
  • endovac
• 
• managment
  • calm yourself, calm patient
  • reassure everything will be okay, antibacterial can cause some damage to tissue, most cases it will return to normal in time
  • monitor tooth to encourage any drainage
  • antibiotic cover, in cases of evidence of secondary infection or debridement imcomplete
  • analgesic: nuromol, diclofenac dexamethasone

Air Embolism

• systematic review
  • drying using air under pressure
  • apical size 45-60
• swelling spreading through entire head and neck space following from tooth
• management
  • swelling looks bad, reassure that its just air trapped and not allergic reaction

CaOH2 Extrusion

• just keep monitoring patient, will be fine

Jaw lock

• use biteblock
• microwaveable heat pack
• can even prescribe diazepam (muscle relaxant)

Postop emergency

• most commonly bacteria
  • can extrude out of the root canal
• pretty uncommon
  • only 3%
  • still warn them that theres a chance of flare up
• major predictor
  • preop pain
  • pain on chewing -> occlusal reduction
• other predictors
  • incomplete cleaning
  • females
  • history of flare up
  • retreatments
• follow up phone call shown to be effective in reducing pain Bartlett '05

Three Rs

• review (reassure)
• reassess
• reconsider

Never leave open to drain

Always remove all restoration

• shows caries, cracks, marginal decay