Pain before, during and after
endodontic emergency treatment
• Pain control before emergency treatment • Pain control during emergency treatment • Pain control after emergency treatment • Rules of thumb:
There is ample evidence that:
 Pretreatment with antibiotics is not beneficial and seems  antibiotics are not efficacious in preventing post- to have no therapeutic benefit treatment symptoms of pain or swelling (flare-ups) (Longman et al., J Dent 2000) Antibiotics are not an alternative to dental
intervention, they are an adjunct to it (Abbott et al., Aust
 antibiotics are ineffective for pain relief in the case of Dent J 1990; Martin et al., Br Dent J 1997) irreversible pulpitis (Nagle et al., Oral Surg 2000)  Antibiotics are indicated if there is a diffuse spreading  antibiotics are ineffective for pain relief in the case of infection or evidence of systemic symptomatic apical periodontitis (Fouad et al., Oral Surg involvement (feeling of malaise; 1996; Henry et al., J Endod 2001; Torabinejad et al., J Endod elevated body temperature) (Longman et al., J Dent 2000)Corticoids are effective for the prevention of post-
Corticoids are effective for the prevention of post-
treatment pain :
treatment pain :
 Double-blind parallel-randomized clinical study: 30 mg  Numerous clinical trials have shown that pre-treatment with prednisolone 30 min before root canal treatment (oral) > oral corticoids is effective in reducing post-endodontic pain significantly less post-operative pain (Jalalzadeh et al., J for at least 12 hours (Marschall et al., J Endod 1993; Glassman Endod 2010) et al., Oral Surg 1989; Mehrvarzfar et al., Aust Endod J 2008;  Placebo-controlled study > pretreatment with 4 mg Liesinger et al., J Endod 1993) dexamethasone > significantly less post-endodontic pain  Oral administration of 30 mg prednisolone or 0.75-4 mg after 4-12 hours after treatment (Pochapski et al., Oral Surg dexamethasone 30-60 min before treatment

Effective for the prevention of post-treatment pain are:
• Pain control before emergency treatment  ibuprofen 800 mg (Jackson et al., J Am Dent Assoc 189; • Pain control during emergency treatment Doroschak et al., J Endod 1999)  if patients may not be able to tolerate non-steroidal anti- inflammatory drugs (NSAIDs) (gastro-intestinal disorders, • Anodyne medicaments active asthmatics, hypertension) > acetaminophen • Pain control after emergency treatment 1000 mg (Moore et al., J Am Dent Assoc 1986)  In general, ibuprofen is more effective than acetaminophen (Dionne et al., J Clin Pharmakol 1983)Irreversible pulpitis of mandibular molars:
• Anaesthesia in the maxilla:  Single inferior alveolar nerve block injection is ineffective  Infiltration injection in 30-80% of patients with diagnosis of irreversible  Palatal injection > 0.3 ml, premolars and molars pulpitis (Nusstein et al., J Endod 1998; Reisman et al., Oral  Periodontal ligament injection > 0.2 ml per injection; two Surg 1997; Claffey et al., J Endod 2004) injections per root > sufficient for endodontic procedures  Premedication with ibuprofen > significantly deeper in 60-70% of cases (Meechan, Int Endod J 2002) anaesthesia during root canal treatment (Modaresi et al., Oral Surg 2006; Parirokh et al., J Endod 2010)1 hour before local anaesthesia 200 mg ibuprofen
• Supplemental injections: intrapulpal injection • Anaesthesia in the mandible:  Effective intrapulpal injection depends on back-pressure  Inferior alveolar block injection  Effect of intrapulpal injection is independent of the  buccal infiltration solution used (VanGheluwe & Walton, Oral Surg 1997)  Mylohyoid infiltration > branches of the mylohyoid nerve > second and third molars  Mental foramen injection > premolars and first molar  Periodontal ligament injection > 0.2 ml per injection; two injections per root Supplemental injections: intraosseous injection Supplemental injections: intraosseous injection  Direct access to the cancellous bone  Onset of anaesthesia is immediately (Gallatin et al., J Am  Perforate the cortical plate with rotating drill > unattached Deent Assoc 2003) gingiva, distal to the tooth to be anaesthetised  Up to 91% successful in gaining total pulp anaesthesia in molars with irreversible pulpitis (Nusstein et al., J Endod 1998)  Pain of perforation  Perforator breakage > about 1% (Reader & Nusstein, Endodonticc Topics 2002)  Systemic effects > in about 50-96% of cases increase in X-tip (Dentsply Tulsa) heart rate > 23-28 beats per minute (Reader & Nusstein, drill = hollow needle Endodonticc Topics 2002) • The "hot" tooth • Pain control before emergency treatment  If non of the afore mentioned measures blocks the pain in • Pain control during emergency treatment a patient with painful pulpitis, last resort >  Application of Ledermix or eugenol to the exposed pulp • Pain control after emergency treatment  Anodyne medicaments suppress the inflammation > better effect anaesthetic in the next appointment (2-3 weeks later) • Pain is not an indication for antibiotic treatment (Henry
et al., J Endod 2001) • Again, antibiotics are only indicated when the patient is febril and for patients who present with cellulitis Pain Research Unit, Department of Anesthesia, Oxford;Analgesics are mere an adjunct to causal treatment
• Causal endodontic treatment > more than 50% pain reduction by one day, about 90% by 2 days (Doroschak et al., J Endod 1999) • Post-operative prescription of analgesics only for 2
• Meta-analysis of the effectiveness of non-steroidal anti- • First analgesic should be taken directly after the inflammatory analgesics > NSAIDs were either as endodontic treatment effective or more effective than codeine-based • Analgesic should be taken „by the clock" > for the first analgesics (NSAIDs were also associated with fewer 2 days every 6 hours (Keiser & Hargreaves, Endodontic
complications (Biddle, AANA J 2002) Topics 2002) • Analgesics of first choice for post-operative pain: ibuprofen 800 mg (Holstein et al., Endodontic Topics • Patients who cannot tolerate NSAIDs > acetaminophen

Source: https://nvve.com/assets/files/Congressen_2/2011maart11/Hand-out_prof.dr.Schafer.02.pdf


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Viterol.A (viatrozene gel) 16% and patients with sunburn should beadvised not to use the product until ful y recovered. • Weather extremes, such as wind or cold, also may be irritating to patients under treatment with Viterol.A. Drug Interactions: Concomitant use of potential y irritating topical products (medicated or abrasive soaps and cleansers, soaps and cosmetics that have a strong drying ef ect, and products with high concentrations of alcohol, astringents, spices, or lime) should be approached with caution. Particular caution should be exercised in using preparations containing sulfur, resorcinol, or salicylic acid in combination with Viterol.A.