Powerpoint-präsentation

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

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