#D3/S2/W5
#Endo

Endodontic pain

• result of inflammatory process in pulp and or periradicular tissues
• microbial and nonmicrobial aetiologies
• production of inflammatory mediators
  • nociceptor activation and sensitisation in pulp/PDL/bone
  • increased vascular permeability -> inflammatory exudate -> increased tissue pressure -> nociceptor activation -> nociceptor sprouting (increased receptivity)

Principles for managing endodontic pain

3D approach

• diagnosis, definitive treatment, drugs
• optimal pain management combines pharmacological and nonpharmacological treatment strategies

Diagnosis

• listen to chief complaint
• reproduce it using objective tests
• pulpal and periapical diagnosis

Definitive treatment

• reduce/eliminate irritant
• reduce elevated interstitial tissue pressure
• reduce tissue levels of inflammatory mediators
• options
  • pulpotomy
  • pulpectomy
  • root canal debridement
  • incision and drainage
  • occlusal reduction

Drugs

• LA
• intracanal medicaments
• systemic analgesics
• systemic antibiotics (when indicated)

System of diagnosis

Medical and dental histories
Hx of presenting complaint

EO

• swelling
• trismus
• TMJ assess
• masticatory muscles
  IO
• soft tissues
  • swelling
  • sinus tracts
• dentition
  • occlusion
  • restorations
  • discolourations
  • caries
  • fractures
  • exposed dentine
• periapical tests
  • percussion (tenderness and tone)
  • apical palpation
  • selective loading of tooth
  • selective cuspal loading
• Periodontal examination
  • mobility
  • fremitus
  • probing (depth and width)
• pulp sensibility tests

Radiographic examiantion

• PA and bitewing
• 3d cbct is helpful too

Diagnostic outcome

• record pulpal and periapical diagnosis
• if diagnosis clear -> trt planning follows
• if diagnosis unclear, wait and watch or refer

Treatment planning

• diagnosis determines treatment options
• informed consent
• patient anxiety management
• profound anaesthesia
• definitive treatment
  • reduce irritant
  • reduce inflammatory mediators and elevated tissue pressure
• adjunctive pharmacological therapy
• follow up

Types of Endodontic pain

Pre treatment pain

• profound anaesthesia
  • LA less effective in pt with inflamed tissue
  • irreversible pulpitis 8x greater failure rate of LA
  • soft tissue anaesthesia not accurate predictor of dental anaesthesia
  • review pathologic reasons for LA failure
  • review supplemental LA techniques

symptomatic irreversible pulpitis +- SAP

• removal of inflamed pulpal tissue
• complete cleaning and shaping if time permits (+ patient factors)
• pulpotomy or pulpectomy
• occlusal reduction
• Pulpotomy
  • acute pain of pulpal origin, absence of SAP
  • removal of coronal pulp without penetrating radicular pulp
  • highly effect (90%) success
  • presence/abssence/type of dress had no impact
  • vs partial pulpectomy which traumatises inflamed tissues and increased pain levels
• Pulpectomy
  • complete with establishment of WL
  • partial pulpectomy or overinstrumentation can increase pain
  • intracanal medicament
• Pharmacological pain management
  • preop pain strong indicator of post op pain
  • analgesics such as
    • NSAIDS, corticosteroids
    • paracetamol
    • opioids
    • long acting LA
  • NSAIDS
    • ibuprofen, naproxen, celecoxib
    • first drug of choice
    • blocks production of AA metabolites (prostaglandins)
    • peripherally as analgesic, anti-inflammatory, centrally as anti pyretic (reduce temp)
    • very effective, affinity for plasma proteins therefore preferentially distributed to inflamed tissues by exudate
    • still potential for adverse effects
    • contraindication
      • kidney impairment
      • heart failure
      • active GI ulcer or bleed
      • corticosteroid, anticoagulants
      • multiple risk factor for NSAID toxicity
      • pregnancy
  • Paracetamol
    • central acting analgesic and antipyretic (no anti inflammatory)
    • analgesic ceiling 1000mg dental pain
    • low incidence adverse effects
    • max dose daily 4g/day
  • Opioids (oxycodone, tramadol)
    • act centrally at opiate receptors to provide analgesia
    • sever pain only: adverse effects + abuse potential
    • combine with peripherally acting drug increases efficacy
    • DONT USE CODEINE
    • oxycodone preferrable, greater efficacy and less drug interact than tramadol
  • Corticosteroids (dexamethasone)
    • anti inflammatory and immunosuppressant
    • significantly reduce post op pain 6,12 ,24 hours
    • rearely indicated in dent due to adverse effects
    • short course 3 days only
  • long acting LA
    • reduce input from primary afferent neurons reduces central sensitisation (signal amplification in higher order neurones)
    • bupivicaine reduced post op pain 6 12 hours
  • antibiotics
    • irreversible pulpitis is inflammatory condition
    • antibiotics not indicated
    • not effective for pain relief
  • Preemptive analgesia
    • pre medication (30min prior to treatment) NSAID or paracetamol significantly reduces post treatment pain
    • administration while patient is still in dental chair
  • PROTOCOL mild to moderate
    • Ibuprofen 400mg 6-8 hourly (no more than 5 days), PLUS
    • Paracetamol 1000mg 4-6 hourly (max 4g / 24 hours)
    • To prevent buildup of arachidonic acid metabolites: First dose should be taken before loss of local anaesthesia. taken ‘by the clock’ rather than ‘as needed’ (PRN)
  • **PROTOCOL severe **
    • Ibuprofen 400mg 6-8 hourly (no more than 5 days), PLUS
    • Paracetamol 1000mg 4-6 hourly (max 4g / 24 hours), PLUS
    • Oxycodone 5mg 4-6 hourly (no more than 3 days)
    • oxy precautions
      • take dose only when needed
      • stepwise discontinuation as pain levels reduce

Pulpal necrosis with apical pathosis

• pain is due to periapical inflammation resulting from bacterial irritants within the root canal
• treatment involves
  • remove/reduce intracanal bacterial irritants
  • relieve apical fluid pressure (when possible)
• complete chemomechanical debridement is treatment of choice
• if limited time, partial debridement at estimated working length
• encourage drainage through the tooth: apical patency
• canals should not be enlarged without establishing working length
• intracanal medicament: steroid based medicament (ledermix) more effective than CH paste
• access never left open for drainage
• occlusal reduction
• swelling may present as either localised soft tissue abscess or diffuse spreading cellulitis
• abscess
  • more chronic
  • localised collection of pus surrounded by granulation tissue
  • localised fluctuant swerlling
  • incision and drainage indicated
    • reduce tissue pressure
    • remove irritants
    • prevent spread
• cellulitis
  • acute presentation of infection
  • spreading inflammatory exudate along subcut spaces and fascial planes, diffuse, hard indurated
  • +- limited opening, difficulty swallowing, systemic signs
  • dangerous due to inability of host defences to localise the lesions
  • urgent referral to OMFS/hospital
    • extraoral drainage, intravenous AB and pain Mx
    • once stable proceed with RCT or exo
• difficulties with LA
  • tooth may be painful to manipulation/movement during tx
  • ST swelling: regional blocks + infil both sides of swelling
  • intraosseous, PDL, intrapulpal injections contraindicated (painful and ineffective) (reader and nusstein 2002)
• Pharmacological pain managemetn
  • same as others
  • warn pt there will still be pain
  • pain should subside over 2-3 days
• pharm management of infection
  • acute dento alveolar infections treated solely by establishment of drainage and removing source
  • antibiotics indicated as an adjust to operative treatment
    • diffuse spreading infection (cellulitis)
    • systemic involvement
    • unable to remove the source (trismus)
    • medically compromised pt
    • amoxicilling 500mg TID
    • if non responsive add metronidazole or which to clindamycin 150mg QID
    • if deteriorates (spreading infection) OMFS referral for hospitalisation

Interappointment Pain

Severe (necessitating and unscheduled visit

• rare, incidence approx 3%
• related to patient presenting factors not treatment procedures
• factors associated with increased flare up risk
  • pulpal necrosis, SAP/ AAA
  • pre-operative pain and or swelling
  • large periapical radiolucent lesion
• factors associated with reduced flare up risk
  • vital pulp, sinus tract
• definitive treatment depends on preop Dx and current findings
  • ensure complete debridement
  • accurate WL
  • incision and drainage if indicated
  • occlusal reduction

Postobturation Pain

severe necessitating an unscheduled visit

• rare
• pain levels after appt correlate to pain levels before appointment
• if root filling is adequate: conservative management
• inadequate root filling or persistent pain: endodontic revision

Pain of non-endodontic origin

• potential for misdiagnosis
• patients with eprsisting pain after endodontic treatment: 62% were found to have pain of non endodontic origin
• useful pain consultants
  • endodontists
  • orofacial pain specialist
  • oral and maxillofacial surgeons

Common features of odontogenic pain

• identifiable cause
• thermal sensitivity (pulpal)
• percussion sensitivity (AP)
• localised pain (pulpal may refer)
• pain quality: dull, aching, throbbing
• unilateral
• can reproduce pain during exam
• pain eliminated by LA injection

Common features of non-odontogenic pain

• no obvious dental cause
• chronic pain not responsive to prior dental interventions
• unable to reproduce the chief complaint by dental provocation tests
• pain quality: burning, electric, stabbing, dull ache
• multiple painful teeth / bilateral / broader pain referral
• consistent relief of pain by LA injection

Musculoskeletal origin

• myofascial pain (TMD)
  • typically related to parafunction / stress
  • deep dull aching pain, diffuse, not restricted to a tooth
  • pain may refer to cheek, ear, forehead, teeth
  • exacerbated by palpating affected masticatory muscles
  • pain on maximum mouth opening
  • management: homecare, splint, referral
    Neuropathic origin
• trigeminal neuralgia
  • paroxysmal intermittent intense pain:
  • severe shooting electric, lasting only a few seconds
  • confined to one or more divisions of trigeminal nerve unilaterally
  • trigger points: tactile stimulation evokes paroxysmal attack
  • pain not restricted to a tooth
  • management: referral
• atypical odontalgia
  • no identifiable cause but often associated with trauma or inflammation
  • diffuse pain related to a tooth, group of teeth or edentulous site
  • usually continuous pain dull ache throb burning
  • sympathetic nervous system may be involved, sensation of warmth and swelling in region
  • chronic pain (>4mo) multiple ineffective dental interventions
  • pain location vary with time
  • management: referral
    Neurovascular origin
• migraine
  • episodic vasodilation activating perivascular nociceptors
  • dull throbbing pain associated with other sensory symptoms: nausea, visual disturbance, mood change, sensitivity to light and sound
• cluster headache
  • more intense pain, hot, burning, stabbing, paroxysmal
  • associated with rhinorrhoea, nasal congestion, lacrimation
  • involves maxillary posterior teeth, sinus, retroorbital areas
    Inflammatory origin
• sinusitis
  • pain referral to dentition + acute neuritis of dental nerves
  • diffuse throbbing aching, often unilateral, exacerbated by fchewing
  • infraorbital pressure sensation. sinus tender to palpate
  • pain may increase with head dip, coughing, sneezing
  • nasal tract on affected side blocked / discharge
  • multiple maxillary posterior teeth involved (tender +- thermal sensitivity)
  • radiology: thickened sinus membrane, fluid level, opacification
  • management: referral, antibiotics vs antihistamine/decongestants
    Systemic disorders
• cardiac pain: refer to L posterior mandible 10% of cases
• herpes zoster: dental pain preceding eruption of vesicles
• fibromyalgia: pain modulating condition, may have atypical pain
• neoplasia: 1.2% patients with non specific jaw pain: metastases in mandible
  • dysesthesia / paresthesia
  • atypical radiographic apperance