Category Archives: Pain Management

it’s vital…with no fillings…but it hurts!

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Radiographs can be so deceiving! This radiograph of the first quadrant looks so calm, so unassuming…everything looks normal. What you didn’t see was the patient attached to this radiograph – having extreme, radiating pain. When everything looks fine on the radiograph, and we have a quadrant full of unrestored or minimally restored teeth, my spidey sense tells me to pick up a probe, and also a transilluminating device. In this particular case, there were no isolated deep probing depths (often suspicious of a root fracture), but transillumination revealed a cracked tooth. The pain can likely be ascribed to the process of “fracture necrosis” – eventual necrosis caused by a significant crack from the outside of the tooth to the pulp. A crack is just one of five types of fractures, which also include craze lines, cuspal fractures, root fractures, and a split tooth. Each are managed a little differently, depending on the presentation.

In this case, we performed a pulpectomy, and used the microscope to look into the crown. It did not appear that the mesial-distal crack extended past the CEJ. The patient had a temporary crown placed that week – and the tooth became comfortable over the ensuing weeks. This is often a nice way for us to ensure the tooth will be comfortable under a crown – an orthodontic band often serves the same purpose. The endodontic therapy was then completed. Even despite the good restorative work that was eventually completed, a tooth with a crack always has a long term guarded prognosis.

Teeth with cracks and fractures can be difficult to detect, visualize, diagnose, and treat. The prognosis of teeth with cracks and fractures also comes with uncertainty and risk. Furthermore, the symptoms of teeth presents with cracks and fractures run the gamut from mild biting sensitivity to severe and radiating pain. However, a few visual aids, like a transillumination light, magnification, and the trusty old periodontal probe can help us to diagnose and manage such cases.


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I’m having a flare-up!

When our patients experience a “flare-up”, we wish they were experiencing a transcendental jazz trumpet experience, and not the other kind, the endodontic kind!

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Fortunately, the reported incidence of flare-ups is relatively low, generally somewhere between 1-8%.  But when it happens, no one is happy, which is a negative experience for the patient, of course, but is hard on the clinician too, especially when we secretly congratulated ourselves only 12 hours earlier for getting through that tough and calcified access or for creating one of the most beautiful obturation radiographs known to man. It can happen to any of us, and we cannot predict who, exactly, will experience a flare-up.

Definition:  moderate to severe pain hours or days after initiation or completion of endodontic treatment, with or without swelling.

Etiology & Diagnosis:  the main culprit is usually microbes, but can be due to mechanical or chemical reasons too.  Over-instrumentation, incomplete instrumentation, apical extrusion of infected debris, and the irrigants or sealers used can all contribute to the occurrence of a flare-up.  The diagnosis of a flare-up is often simple, but is important to rule out pain from adjacent teeth and pain of non-endodontic origin.  The local considerations for the tooth itself might include a crown or root fracture or an untreated canal (particularly if there is temperature sensitivity).  We also need to identify any signs of spreading infection, osteomyelitis, fever, swelling, etc., and treat that appropriately, with the appropriate antibiotics and very careful follow-up, or referral to an oral surgeon if there is potential for danger, which can develop extremely quickly.

Management:

1. Reassure your patient: patient does appreciate when we explain what is happening and why, and the steps we are going to take, including following up.

2. Definitive treatment:

  • opening the tooth up under a rubber dam again, to provide re-instrumentation to a proper working length with copious irrigation.  This also gives us a chance to search for any untreated canals, and allow for any suppurative drainage.  If there is drainage, allow the tooth to drain, which can take several minutes.  Avoid leaving the tooth “open” – that is, without a temporary filling in the access- and always place an intra-canal medicament, such as calcium hydroxide.  Occlusion can be reduced.
  • incise and drain (I&D) if there is vestibular swelling.  If the abscess is localized, generally antibiotics are not needed unless there are other signs of systemic infection, cellulitis, poor drainage, or immune compromise.
  • cortical trephination – the jury is out on this one.  While this is not indicated routinely, it should be considered in areas with dense and thick cortical plates (i.e. lower molars).

Drugs: NSAIDS such as ibuprofen address inflammation very well, but some patients may require stronger analgesics, or combinations of analgesics for adequate pain relief.  My “go-to” is generally ibuprofen, and I rarely find that I need to prescribe narcotic analgesics.  However, I will consider acetaminophen only (plus or minus an opioid), other NSAIDS, or combinations of analgesics, depending on the patient’s risk of GI bleeding.  Antibiotics will not reduce post-treatment pain or decrease the risk of developing a flare-up when used prophylactically, but are indicated when there is sign of systemic involvement, presenting as fever, malaise, cellulitis, lymph node involvement, trismus, rapid onset of severe infection, or a compromised immune system.

Prevention: it is important to inform your patients that they may experience a flare-up!  Tell them what to expect, how to identify the symptoms, and how they may reach you if this should happen.  I discuss this possibility with every patient.  If your patient comes to you with significant pain before you even start treatment, now is the time to consider pre-operative dosing of analgesics, and possibly a single oral dose (some prefer supra-periosteal infiltration) of an appropriate steroid (a common dose is 4 mg of dexamethasone) if there is no know contraindications.  Finally, shaping techniques such as a “crown-down” method may help prevent us from pushing infected debris into the periapical area.


‘No’ Treatment is ‘The’ Treatment!

A patient presented with pain in the lower anterior area.  A fairly good-looking and recent root canal (approx. over 2 months old) had been performed on tooth #4.2.  Patient’s pain however had been progressively getting worse since the completion of treatment.  The pain was not occlusion-related and analgesics had not been helping either.  Upon diagnostic testing, all other lower incisors responded normally to cold testing despite showing some evidence of periapical changes.  None of these teeth were previously restored either, except for a class V restoration on tooth #3.2.

The pattern of PA lesion associated with tooth #4.2 (mixed radiopaque-radiolucent lesion), lack of previous restorations and bone pattern changes around vital teeth made me suspicious of periapical cemental dysplasia (PCD).  To confirm my suspicion and to manage patient’s pain (possibly not related to PDC), apical surgery was performed for tooth #4.2.  The biopsy confirmed the final diagnosis of benign fibro-osseous lesion consistent with PCD.

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Six-month recall radiograph confirms the complete healing of the surgical site and the patient has remained asymptomatic.  I cannot explain the biological process involved in patient’s appearance, persistence and resolution of pain but here are some facts about PCD:

  • etiology is unknown
  • mandibular incisors are most commonly involved teeth
  • multiple lesions may be present at different stages: osteolytic (radiolucent), intermediate (mixed) and mature (radiopaque)
  • lesions are always asymptomatic
  • involved teeth are vital

Therefore, vitality testing is the key to diagnosis and radiographic follow-up and frequent observations are the most appropriate treatments for cases like this.


Antibiotics: Knowing When Not To Use Them!

Inappropriately prescribing antibiotics is one of the main contributing factors in the development of antibiotic resistant microorganisms.

The most effective treatment of endodontic infections are: removal of the source of infection through endodontic treatment, incision for drainage, or extraction.  Antibiotics are used in addition to appropriate treatment to aid the host defenses in the elimination of remaining bacteria.

Antibiotics are INDICATED when there is systemic involvement or evidence of spread of infection.  Signs and symptoms include: fever >100F, malaise, cellulitis, unexplained trismus, lymphadenopathy, rapid onset swelling.  Antibiotic prophylaxis should also be considered for medically at-risk patients, for prevention of infective endocarditis and delayed prosthetic joint infection.

Antibiotics are NOT INDICATED in: teeth with signs of irreversible pulpitis (hot teeth, cracked teeth, teeth with large decays, etc.), teeth with necrotic pulps and a radiolucency, teeth with a sinus tract, and teeth with localized fluctuant swellings.

What to use?  Pen-V-K is the antibiotic of choice for endodontic infections.  Metronidazol should be used in combination with Pen-V-K or clindamycin if patient’s symptoms worsen 48-72 hours after the initiation of treatment.  Amoxicillin is often used for antibiotic prophylaxis cases.  Clindamycin is the antibiotic of choice for patients allergic to penicillins or when a change in antibiotic is indicated.  Amoxicillin-Clavulanate should be reserved for unresolved infections and patients who are immunocompromised.

[AAE Colleagues for Excellence – Summer 2006]


Too Hot to Handle!

One common question that many of my friends ask me is “How do you deal with a hot tooth?”

After giving adequate block injections and local infiltrations, I usually use intraligamental or intraosseous type of injections. My first choice for a few years has been using a syringe called Paroject. This syringe is used for intraligamental injections which is in a way intraosseous as well since the pressurized anesthetic solution in the PDL space will penetrate into the adjacent cancellous bone. I give 6-point intraligamental injection around the hot tooth using local anesthetic without epi and this usually does wonders.

Another effective method is using the intraosseous anesthesia with the Stabident and X-Tip systems. The details of the two systems can be reviewed in the article “Intraosseous Anesthesia” from the Endodontics: Colleagues for Excellence (Winter 2009) publication by the American Association of Endodontists (AAE).

Have I been 100% successful with all the hot teeth I have dealt with in the past few years? Absolutely not! If that happens, don’t forget there is always the good old practice-builder technique: the “Intrapulpal Injection“.


Don’t Let the Sun Set on Pus!

One of my favorite instructors at UBC, Dr. Matthew, used to say this all the time and I think it is a very good advice. Here is a case that walked into my office a few weeks ago. A young female patient developed a very large and extremely painful swelling over night on the roof of her mouth. She had been in pain for a few days prior to the the development of swelling for which she had been placed on appropriate type and dosage of antibiotics. Tooth#25: previously treated ~5 years ago, crown came off due to long-standing leakage one month ago, cemented back on permanently, pain started 2 weeks ago, referred out by her dentist for re-treatment.

At emergency appointment, I&D was performed. For achieving appropriate and safe drainage, the tip of the blade should make contact with the bone and the incision line must be parallel to the path of nerve and blood vessels in the area. Rinse the area with saline and apply digital pressure with moist gauze. I personally do not place a drain in.

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When the patient returned a week ago, she was comfortable and ready to continue with the initiation of re-treatment. Antibiotics alone would have not helped in this case and there is usually no real need for initiation of re-treatment at the emergency appointment.


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