History of Endodontics aae/abe

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Salivary Gland Pathology – pain present at time of eating, sialography, CT/MRI


  1. Primary SCC or metastatic tumors (mand.) – Numbness (#1), jaw pain

What is a NICO lesion?
Neuralgia Inducing Cavitational Osteonecrosis – aka – “Ratner’s Bone Cyst”

  1. Diagnosed by exclusion, technetium scan or multiple radiographs

  2. Histology – Ischemic Osteonecrosis

  3. Symptoms – mimics: Atypical Facial Pain or Trigeminal Neuralgia

  4. Radiographic findings – subtle findings

  5. History – possible history of trauma, extraction or infection

  6. Treatment – decorticate & curettage (high incidence of recurrence)

AAE Position statement:

  1. Suspected NICO lesion should be referred to Orofacial Pain specialist for evaluation, diagnosis, and treatment

  2. Extraction of NSRCT tooth with suspected NICO lesion is unethical

Non-odontogenic pain

P – Psychogenic – Manchausens

I – Inflammatory – Sinusitis
N – Neurovascular – Migraines, Cluster headaches; Neurogenic – Neuroma, Neuritis
S – Systemic – Myocardial Infarction, Neoplastic
M – Musculoskeletal – Myofacial pain disorder
Differential Dx:

Myofacial pain disorder, Neurovascular, Neurogenic (Neuroma, Neuritis), Neuropathic (Neuralgia, Atypical Facial Pain), Psychogenic, Cardiac, Sinus, Salivary or Primary/Metastatic (mandibular - numbness/jaw pain)

Cranial Anatomy

  1. Arterial Supply:

R atriumR ventriclePulmonary arteryLungsPulmonary veinL atriumL ventricleAortaCommon Carotid arteryExternal Carotid arteryMaxillary artery

    1. Maxillary Posterior teeth: Ptergyopalatine arteryPSA artery

    2. Maxillary Anterior teeth: Pterygopalatine arteryPSA arteryMSA artery

    3. Mandibular Posterior teeth: Mandibular arteryInferior Alveolar artery

    4. Mandibular Anterior teeth: Mandibular arteryInferior Alveolar arteryIncisive artery

  1. Venous Drainage:

    1. Mandibular Ant/Post teeth: Inferior Alveolar vein

    2. Maxillary Anterior teeth: Infraorbital vein

    3. Maxillary Posterior teeth: directly into the Maxillary vein

Maxillary veinPtergyoid venous plexusRetromandibular veinInternal Jugular veinBrachiocephalic veinSuperior Vena CavaHeart (via R. Atrium)

Cranial Anatomy

Cranial Nerves Supply:

Brain stemTrigeminal nerve (C.N. V), 3 branches of Trigeminal:

  1. Ophthalmic - sensory only:

    1. forehead, upper eyelid, nasal mucosa, frontal sinus

  2. Maxillary (foramen rotundum) – sensory only

    1. Lower eyelid, cheek, upper lip, maxillary teeth/gingiva, palate, maxillary/ethmoid/sphenoid sinuses

    2. PSA - Maxillary Molars

    3. MSA - Maxillary Premolars, MB root of Max Molar (see Walton)

    4. ASA - Maxillary Canine, Incisors

  3. Mandibular (foramen ovale) – sensory and motor

    1. Sensory - lower lip, mandibular teeth/gingiva, chin, lower face, tongue (lingual n) via: Buccal, Auriculotemporal, IAN, Lingual nerves (BAIL)

    2. Motor - muscles of mastication, mylohyoid, ant. Digastric

    3. IAN - Mandibular Molars, Premolars

    4. Incisive Branch - Mandibular Canine, Incisors

Flare-ups/Post-op Pain

What is a flare-up?

  1. Reader – Post-operative acute exacerbation of symptoms resulting in moderate to severe pain and/or swelling

  1. Walton – Severe pain and/or swelling within a few hours to few days requiring unscheduled visit and active treatment

  1. AAE – Acute exacerbation of asymptomatic pulpal or periapical pathosis after the initiation or continuation of NSRCT

  1. Tsesis – Strong pain/swelling occurring within 48 hours

What are the causes of flare-ups?

  1. Seltzer/Naidorf 1985

    1. Extrusion of irritants into apical tissues (medicaments, irrigating solutions)

    2. Changes in periapical tissue pressure (aspiration of bacteria/tissue fluids)

    3. Specific Bacterial species (Sundqvist and BPB)

    4. Pro-inflammatory mediators and inflammatory processes associated with acute inflammatory reaction incited by instrumentation of the canal

  1. Siqueira 2003

    1. Extrusion of infected debris

    2. Changing microbial flora of canal

    3. Changing Redox potential of canal (introducing Oxygen)

What is the incidence of flare-ups?

  1. Walton/Fouad 1992 – 946 visits, Flare up Overall incidence: 3.2%, Severe pre-op pain: 19%, Localized/diffuse swelling: 15%, AAA: 13%, Necrotic pulp: 6.2%, SAP: 5%, Vital pulp: 1.3%

  1. Trope1.8% overall, 13.6% Retx/AP/single visit

  1. Tsesis – Meta-Analysis - 8.4% overall

  1. Eleazer/Eleazer3% one visit, 8% two visit

What is the incidence of flare-ups? Continued

  1. Torabinejad 1994 – Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps

    1. Age

    2. Sex of patient

    3. Presence of preoperative pain

    4. Presence of allergies

    5. Absence of PA lesions

    6. Sinus tract

    7. Retreatment cases

    8. Those receiving prescribed analgesics

Factors that had no effect on the frequency of emergencies

    1. Presence of systemic disease

    2. Use of intracanal medications

    3. Penetration of the foramen with small instruments during length determination

Do prophylactic antibiotics decrease flare-ups? NO

  1. Walton/Chiapinelli 1993Pulp Necrosis/Chronic (Asymptomatic) Apical Periodontitis – NSD between Prophylactic Penicillin (2 g at time of appt/ 1g 1 hr post op) and Placebo for post-treatment (Pulpectomy) incidence of Flare-ups, Pain, Swelling, and Severity of pain reported

  1. Pickenpaugh/Reader 2001Pulp Necrosis/Asymptomatic Apical Periodontitis – NSD between Prophylactic Amoxicillin (3 g 1 hr prior) and Placebo for incidence of Flare up post-op (Pulpectomy)

  1. Fouad/Rivera/Walton 1996Localized AAA – NSD between course of Pen VK 500 mg, Placebo, and No treatment following Pulpal debridement + I&D (if needed) + 600 mg Ibuprofen (pre-op and q6h post-op) for Reduction of symptoms or Speed of recovery. NO benefit from penicillin for treatment of localized acute apical abscess when local treatment measures are completed!

Do prophylactic antibiotics decrease flare-ups? NO

  1. Nagle/Reader 2000Untreated Symptomatic Irreversible Pulpitis – NSD between pre-treament course of Pen VK 500 mg (7 days) and Placebo for Reduction of Pain, Percussion Pain, and Number of Analgesics taken for the 7 days prior to treatment. Penicillin should NOT be prescribed to treat irreversible pulpitis as it does not reduce pain.

  1. Henry/Reader 2001Pulp Necrosis/Symptomatic Apical Periodontitis – NSD between course of Pen VK 500 mg (7 days) or Placebo for reduction of post-operative Pain, Percussion Pain, and Number of Analgesics taken. Post-op admin. of Penicillin does not reduce symptoms for symptomatic necrotic teeth with periapical radiolucencies.

Do prophylactic antibiotics decrease flare-ups? YES

  1. Torabinejad 1994 – Ibuprofen, ketoprofen, erythromycin base, penicillin, and methyprednisolone plus penicillin were more effective than placebo for reduction of flare-ups within the first 48 hours following pulpectomy

  1. Morse 1987 – 1 day of high dose Pen VK reduced flare-up incidence from 20% to 2%

What is the incidence of Interappt pain?

  1. Harrison/Baumgartner 1983 – Incidence of Interappt pain (Asymptomatic pre-op): No pain: 55.5%, Slight Pain: 28.8%, Moderate-Severe Pain: 15.7%; NSD between vital and necrotic teeth

  2. Georgopoulou 1986 – Pain after chemomechanical debridement: No pain: 57%, Mild pain: 21%, Moderate pain: 15%, Severe pain: 7%

  3. Glennon/Ng IEJ 2004 – Prevalence of Post-preparation (necrotic w/AP) pain within 48 hours: 64.7%, Pain  day 2 in 64%. Severe pain: 9.9% (day 1), 6.3% (day 2). Predictors: Pre-op pain, Pre-op swelling, Molars

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