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Restorative Dentistry, Endodontics
Number 11 November 1978 rt1693 Pagel
Diagnosis and management of pain of pnipal origin
Mahmoud Torabinejad, D.M.D., M,S.D. Associate Professor of Endodontics, School of Dentistry Address: Loma Linda, California
Pulpal and periapical pain, or a combination of both, are the major reasons for patients to seek dental treatment. Mechanical, thermal, chemical or electrical stimulation of pulp tissue can result in inflammation of dental pulp. Pulpal inflammation is like other inflammatory reactions in other tissue sites; it is an attempt to localize, destroy and remove the irritants.i Since pulp tissue, and to a lesser degree periodontal ligaments, are encased in hard tissues, inflammation creates an increase in fluid volume in a restricted space which can only result in severe pain. Proper diagnosis and timely treatment are very important factors in providing relief of pain.
Complete examination and proper tests are keys to successful treatment of pulpal pain. After taking a careful medical history, subjective questions and objective examinations should be performed. The questions should relate to 1. the location of pain, 2, the severity of pain, 3. the duration of pain, 4. the character of pain (sharp or dull, localized or diffuse), and 5. the causes of pain. Although in most instances patients can pinpoint the location of their discomfort, limitation of the examination to only one tooth can easily result in
"Quintessence International" 11/1978
incorrect diagnosis. Therefore, both arches should be examined to eliminate the possibility of overlooking other causes such as: referred pain, sinusitis, bruxism or a cracked tooth. The objective tests now follows and should include a general examination of soft and hard tissues. Teeth are examined in the usual manner with the aid of a mirror and explorer checking for discolored crowns, sinus tract stomas, recurrent caries, pulpal exposures as well as fractured teeth. Palpation of the soft tissues overlying the apex of a tootb with the tip of index finger and percussion of teeth with the end of the mirror handle are also useful tests to determine the extent of pulpal and periapical inflammation. Vitality tests (cold, heat, electricity) can indicate the status of the pulp of the offending tooth. In addition, these tests, along with the history of pain, can help to determine if the pulpitis is reversible or irreversible. Periapical and bite wing radiographs can disclose the presence of interproximal and recurrent caries, pulpal exposure, internal or external résorption and periapica! pathosis. Probing of the soft tissue surrounding a tooth helps to differentiate pulpal and periodontal disease. For example, an acute periodontal abscess can simulate symptoms of an acute apical abscess. However, in a periodontal
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abscess the tooth pulp is usually vital and a periodontal pocket can be probed. In contrast, the acute apical abscess usually involves a tooth that does not respond to the electric pulp tester and has no periodontal pockets. In addition to the above tests, in some instances, a test cavity and a local anesthetic test are needed to isolate the offending tooth, A simple classification of pulpal diseases whicb cause emergencies is helpful to determine the type of treatment. This classification is as follows: 1. Vital pulp (acute pulpitis, acute pulpitis with periodontitis), 2. Non-vital pulp (with or without swelling). Anesthesia Presence of pain can result in psychological changes in patients. Therefore, special considerations are needed. Frofound anesthesia and a sympathetic reassuring manner can earn the patient's appreciation and cooperation.- Anesthesia of maxillary teeth is usually obtained by subperiosteal injections in the buccal and palatal sites. When mandibular teeth are anesthetized, in addition to an inferior alveolar block, a lingual and a long buccal injection are helpful in anesthetizing other anastomosing fibers. In some instances, although all signs of a profound anesthesia are present, touching the offending tooth can still be painful. Intraseptal and intrapulpal injections can eliminate remaining sensitivity in most cases. I. M a n a g e m e n t of p a i n in teeth with vital pulps A pulp is viable when it responds to vitality tests and bleeds when it is pierced with an endodontic explorer. If a vital pulp is diagnosed to be inflammed 22
irreversibly, i.e., having spontaneous discomfort and lingering pain after thermal tests, the treatment of cboice after occ!usal adjustment is complete removal of the pulp in large and small canals in acute pulpitis, with or without periodontitis. If time does not permit, removal of the coronal pulp tissue is acceptable in acute pulpitis without periodontitis. The medication of choice when the coronal pulp is exstirpated á is the placement of a cotton pellet 1 dampened with formocresol in the pulp chamber.''-'* Incomplete removal of the pulp in acute pulpitis with periodontitis cannot relieve the pain and in most instances a total pulpectomy is needed in these cases. In total pulp extirpation the canals should be irrigated with sodium hypociilorite, carefully dried with paper points, medicated with cresatin or formocresol and sealed with a temporary filling material. Keeping teeth with vital pulps closed after emergency treatment, lessens the total treatment time and increases the cbances for patient comfort.^ At the end of the emergency treatment a mild analgesic is prescribed, to be used if needed. In vital pulp cases no antibiotics are usually necessary. II, M a n a g e m e n t of p a i n in teethwith non-vitalpulps When necrosis of the pulp has occurred, there is a lack of response to vitality tests and absence of viable tissue in the pulp chamber or in the root canal system. In emergency treatment of teeth with necrotic pulps, one of the following situations may be encountered, a) Teeth with necrotic pulps without swelling. b) Teeth with necrotic pulps with swelling (acute periapical abscess).
'Quintessence International" 11/1978
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Teeth with n e c r o t i c pulps without swelling If the pulp responsible for pain is not exposed to saliva, after occlusal adjustment and removal of causative agents, cleaning and shaping of canaUs), they are medicated, and tbe access cavity is closed. In teeth with necrotic pulps exposed to saliva, one of the following therapeutic procedures can be followed: 1. After occlusal adjustment, cleaning and shaping of the canal(s), the canal is medicated and the access opening is sealed with a temporary filling material. Since debridement of the canals can force bacteria present within the canals into the periapical tissues and cause an acute periapical abscess, it is advisable to administer an antibiotic and an analgesic. The patient should be seen within 24—48 hours. 2. After cleaning and shaping of the root canal system, the tooth is left open. Three or four days later, when the patient is comfortable and still on systematic antibiotic therapy, the root canal can be irrigated with sodium hypochlorite, carefully dried with paper points, medicated, and closed with a temporary filling material. If symptoms recur and cannot be controlled, ultimate treatment include: obturation of the root canal system, followed with apicoectomy and retrofill with silver amalgam. Teeth with n e c r o t i c pulps and s w e l l i n g ( a c u t e periapical abscess) The main clinical signs for an acute periapical abscess due to a pulpless tooth are the rapid onset of soft tissue swelling and/or the observation of pus in the root canal after opening into the pulp chamber.••' Radiographic findings for acute periapical abscess range from
"Quintessence internationa!" 11/1978
no periapical change to a large radiokicency. When a localized and ftuctuanl soft tissue swelling is present, in addition to occlusal adjustment and cleaning and shaping of the root canal system, the soft tissue swelling should also be incised. In these cases, after cleaning and shaping of the root canal system, the canal is medicated and scaled with a temporary filling material. In order to allow the drainage to continue, a rubber dam drain can be inserted and sutured in place until the root canal therapy is completed. In acute periapical abscess with localized and fluctuant swelling, the use of systemic antibiotics may not be necessary, particularly where adequate drainage has been accomplished. Treatment procedures for acute periapical abscess with diffuse and nonfluctuant soft tissue swelling are as follows: 1. After occlusal adjustment and debridement of the root canal system, the apical foramen is enlarged to a number 25 or 30 root canal reamer or file. This procedure ensures the presence of a patient apical foramen and it can improve the flow of pus and other exúdate. 2. Do not seal the access opening. It has been recommended that in these cases it is desirable to leave the tooth open for drainage.•'•'*•«••'• 3. An analgesic is prescribed. 4. Systemic antibiotics and hot rinses are used to localize the swelling, 5. When soft tissue swelling becomes localized and flucfuant, the root canal system is cleaned, medicated and closed with a temporary filling material. At this time, the soft tissue swelling can be incised, and a rubber dam drain is inserted and sutured in place. This drain can stay in until the treatment is finished. 23
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Correct diagnosis, concern for the patient, profound anesthesia, and institution of the proper treatment are all factors that will contribute to speedy relief of pain of pulpal origin. Though often the management of patients with pulpal pain require more time and effort than other dental procedures, it is one aspect of dentistry that patients deeply appreciate.
Bibliography 1. Cahn, L. R. The Pathology and Treatment of Periapicat Disease. Brit. Dent. J. llt:57—6t, Juty 18, 1961.
2. Ingle, J. R., Beveridge, E. E. Erdodontics, ed. 2. Philadetphia, Lea and Febiger, 1976, p. 81. 3. Natkin, E. Treatment of Endodontic Emergencies. Dent. Clin. North Am. 18:243—255, Aprit 1974. 4. Weine. F. S. Endodontic Therapy. St. Louis, C. V. Mosby Co., 1976, pp. 132. 137. 5. Weine, F. S,, Healey, H. J.. and Theiss, E. P. Endodontic Emergency Dilemma: Leave tooth open or keep it closed? Oral Surg. 40:531—536, October 1975. 6. Grossman, L. I. Endodontic practice, ed. 8, Phitadetphia, Lea and Febiger. 1975, p. 76. 7. Sheldon, B. A., and Parris, L. Management of Endodontic Emergencies. J. Dent. Child. 37:260—267. May—June 1970.
Jet lag science The author tells of his travels to scientifie eonferenees in California, Puerto Rieo, Chieago, Montreal, Washington and Atlantic City, observing that: "It is hard to realise that the American Society for Artificial Organs is already 23 years old. During this time we have witnessed not only the growth of an entirely new subculture of dialysis nurses, teehnicians, social workers, scientists, salesmen, and politicians, but also the birth of prototypes that someday will replace most parts of man with the possible exception of the* sou! and supcicgo. There ;ire artifical bowels and pancreases and livers, hearts and eyes and ears, prosthetic ureters and plastic bladders, an a 'new device for the treatment of certain cases of male infertility.' Artificial arms can lift, grip, rotate, and move with the freedom of a natural arm . . . Membrane artificial lungs optimise not only O^ delivery but also C0„ removal . . . To the implantable pacemaker must now be added pumps that infuse insulin and electromagnetic sound sources that replace the larynx. Cells are grown on polymer matrices, enzymes ean be put inside red cells, and a calf has lived 160 days with a mechanical heart in its chest . . . " (George Dunea, Cook County Hospital, Chicago, in British Medical Journal 2:752—3, llth Sep. 77)
June 30th-July 1st, 1979 1st Japanese Dental Assistants Congress,
Details from: Quintessence Publishing Co., Ltd., TBR Bldg. 1204, 7 Kojimachi 5-chome, Chiyoda-ku. Tokyo/Japan, Tel.:2 30-23 06. Telex: 2 56 50
"Quintessenoe internationai" 11/1978
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