makalah skenario 3 blok 6

CHAPTER II

CONTENTS

I. Vital Pulp Therapy

I.1. Indications for vital pulp therapy

a. Teeth with incomplete apical development. This in excellent indication for

pulpotomy. Incomplete development of the apex can cause lack of apical

constriction needed to pack the root canal filling. Pulpotomy procedures will

usually keep the apical portion of the pulp vital and allow for relatively normal

root development and closure (apexogenesis).

b. Primary teeth. Calcium hydroxide and zinc-oxide eugenol as capping agents and

calcium hydroxide and formocresol as pulpotomy agents have been reported with

great success in primary dentition. Besides, endodontic therapy will be difficult to

accomplish in primary teeth since it has thin and curved canals, multiple lateral

canals, ramifications, and resorbing roots.

c. Teeth that would be difficult to treat endodontically. The examples are teeth with

sharp apical dilacerations, extremely long multirooted teeth, and third molars

with unusual root shape or number of roots.

d. Teeth with pulpal inflammation confined to a small segment of the coronal pulp.

If there’s only a small segment of the pulp is inflamed, probably adjacent to the

site of exposure, either pulp capping or pulpotomy could remove it.

I.2. Contraindications for vital pulp therapy

a. Teeth in which the canal space could be well utilized to hold a post and core. If

there’s a tiny pulp exposure, the tendency might be to do the vital pulp therapy

and then build up the crown with pin or screw posts in restoration. But, if the pulp

become necrotic later, it will be very difficult to locate the canal through the mass

of restorative materials. Restoration of the tooth probably would have been easier

if the pulp had been removed at the time of exposure with endodontic therapy and

later restoration with a post and core.

b. Splint, bridge, and precission partial denture abutments. If a tooth that is to be

used as a splint, fixed bridge, or precision partial denture abutment is exposed, it

probably should undergo routine endodontics initially.

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c. Teeth involved in complex periodontal therapy and resultant periodontal

prostheses. Pulpal inflammation is often accompanied with severe periodontal

lesions. If these teeth are flapped and the roots are scrapped and curetted during

periodontal treatment, prepared for splinting, temporized, and crowned in

restoration, it is obvious that any pulpal inflammation present will increase.

I.3. Kinds of vital pulp therapy

a. Pulp capping of posterior teeth

Once the exposure occurs, the desired medicament is placed over the pulp

without pressure.

A thin mix of zinc oxide eugenol is placed over the medicament.

A thick mix of xinc oxide eugenol is zinc oxide accelerated with zinc acetate

crystals is prepared and used to close the entire preparation.

The tooth may be restored if symptom free from 1 to 4 weeks later.

b. Formocresol pulpotomy for posterior teeth

Once the exposure occurs, the roof of the pulp chamber is removed.

A sharp, sterile, no. 4 round bur is used to remove the coronal pulp tissue so the

bleeding pulpal stumps only are seen at the floor of the chamber.

Sterile cotton pellets are used to absorb hemorrhage.

After hemostasis is achieved, a cotton pellet is lightly dampened with

formocresol and applied to the pulp stumps for 3 minutes.

A thin mix of formocresol and zinc oxide is prepared and placed on the pulp

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A thick mix of zinc oxide eugenol accelerated with zinc acetate crystals is placed

to provide occlusal seal.

The tooth may be restored if symptom free from 1 to 4 weeks later.

c. Treatment of open apex with vital pulp

A pulpotomy procedure is indicated in the tooth with an open apex to allow

completion of apical closure, as long as the apical pulp remains vital. This is

referred to apexogenesis.

Anesthetic administration and rubber dam application.

The coronal pulp is amputated to approximately the cervical line with a sharp,

sterile, no. 4 bur.

Sterile cotton pellets are used to absorb hemorrhage.

A cotton pellet lightly dampened with formocresol is applied to the pulp stump

for 3 minutes.

A thin mix of formocresol and zinc oxide is prepared and placed on to the pulp.

A thick mix of zinc oxide eugenol accelerated with zinc acetate crystals is placed

to provide a seal to the canal and is followed by a suitable temporary restoration.

The tooth is radiographed at 6-month interval. When apical closure has occurred,

routine endodontic treatment is undertaken. If the pulp becomes necrotic,

apexification procedure is required.

d. Treatment of open apex with nonvital pulp-apexification procedure

Anesthesia is usually not needed. The rubber dam is applied.

The working length is established and the canal is debrided.

A large Hedstrom file may be used to rasp the walls of the canal with heavy

irrigation. The canal is dried with sterile paper points.

A sterile, dry cotton pellet is placed in the chamber, and the access is closed with

zinc oxide eugenol.

1 to 2 weeks later, the rubber dam is again applied and the cotton removed.

The canal is irrigated, the walls again rasped to remove debris, the canal dried.

Place a thick paste composed of calcium hydroxide and CMCP in the debrided

canal. The paste must reach the apical portion of the canal to stimulate the tissue

to form a calcific barrier.

A cotton pellet is placed in the chamber, followed by zinc oxide eugenol, and a

suitable temporary seal.

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At 6 months, the patient is recalled for radiographic examination. There might be

some possibilities:

II. Endodontic Emergencies

II.1. Definition

Endodontic emergencies are usually associated with pain and/or swelling and

require immediate diagnosis and treatment. It is caused by pulp or periapical

disease or severe traumatic injuries.

II.2. Differentiation of emergency and urgency

Emergency is a condition requiring an unscheduled office visit with diagnosis

and treatment now. The visit can’t be rescheduled since the problem is so severe.

Urgency (less critical) is a condition in which the problem is less severe. A visit

may be rescheduled

Questions to determine severity include:

a. Does the problem disturb you sleeping, eating, working, concentrating, or other

daily activities?

→ emergency disturbs patient’s activities

b. How long has this problem bother you?

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→ emergency has rarely been severe for more than a few hours to 2 days

c. Have you taken any pain medication? It is effective?

→ analgesics don’t relieve the pain of a true emergency

II.3. System of diagnosis

a. Medical and dental histories

Medical and dental must be updated (old patient) or taken completely (new

patient). Dental history will include previous dental procedure and chronology of

symptoms.

b. Subjective examination

Purpose: gain information about the pain source and whether it comes from

pulp/periapical

→ questions related to history, location, severity, duration, character, and stimuli

caused or relieved pain → select appropriate objective tests

Pain caused by thermal stimuli, referred : possibly coming from pulp

Pain occurs on tooth contact, well localized : possibly coming from periapical

c. Objective examination

Purpose: repeat the stimuli which causes pain based on the patient report in

subjective examination

If similar subjective symptoms are not reproduced → may not an emergency →

patient may be over-reporting

Include: extraoral and intraoral examination, involving periapical and pulp

vitality test → observation of swelling, presence of defective restoration,

discolored crown, recurrent caries, or fracture

d. Periodontal examination

Probing helps distinguishing endodontic from periodontal disease. Example:

Periodontal abscess : the pulp is usually vital

Acute apical abscess : the pulp is usually necrotic

e. Radiographic examination

Periapical and bitewing radiograph can detect the presence of caries, pulpal

exposure, resorption, and periapical disease.

f. Diagnostic outcome

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The clinical must identify the offending tooth and the tissue (pulpal or

periapical) that is the source of pain. He also must record a pulpal or periapical

diagnosis. Diagnosis is clear → treatment planning.

II.4. Treatment planning

Major cause of painful dental emergency: inflammation (increased tissue pressure

and release of inflammatory mediators). Treatment plan aims to reduce the

irritant or the tissue pressure or removal of the inflamed tissue → pain relief

II.5. Categories

a. Pretreatment emergency-situation in which the patient is seen initially with sever

pain and/or swelling.

b. Interappointment and postobturation emergency the problem occurs after an

endodontic appointment.

PRETREATMENT EMERGENCY

a. Patient management

The frightened patient in pain must have confidence that his problem is being

properly managed.

b. Profound anesthesia

Maxillary anesthesia : infiltration or block injections in the buccal and palatal

region

Mandibular anesthesia : inferior alveolar and lingual nerve block and long

buccal injection (helpful)

Although signs of profound anesthesia appear → access into pulp is painful →

supplemental injection (intraosseous, periodondtal ligament, intrapulpal injection)

c. Management of acute reversible pulpitis

Hyperemia can be localised by asking the patient to point the identify tooth and

making diagnosis based on the visual, tactile, thermal, and radiographic

examination of the isolated tooth.

If a recent restoration has a bad contact point à recontouring.

If persistent painful comes from cavity preparation à chemical cleansing of the

cavity or remove the restoration and replace it with a sedative cement (ex : ZOE).

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The same method can be used if recurrent decay under an old restoration hasn’t

caused pulp exposure.

The best treatment is prevention : use pulp protective under all restoration, avoid

marginal leakagem reduce occlusal trauma if present, properly contour

restoration, avoid injuring the pulp with excesssive heat while

preparing/polishing.

Usually application ZOE as temporary sedative filling will make the pain

dissapear within several days, if it persists or worsens, the the pulp should be

extirpated.

d. Management of acute irreversible pulpitis

The preferably emergencies for both acute irreversible pulpitis (usually

abnormally responsive to cold or heat) is pulpectomy. If the patient describes

pain that last for hours, disturbing sleep or spontaneous or occurs when bending

over, most likely the patient require pulpectomy. The technique for pulpectomy is

as follows :

Anesthetize the affected tooth

Apply the rubber dam

Prepare an access cavity into the pulp chamber

Remove the pulp from the chamber with excavators or curettes

Irrigate and debride the pulp chamber

Locate the root canal orifices and explore the root canals

Extirpate the pulp by sequentially instrumenting with reamers or files to within 1

mm of the radiographic root apex

Irrigate with sterile saline solution, anesthetic solution or sodium hypochlorite

solution

Debride with a barbed broach, fitted loosely so it can be rotated in the root cana

without binding, usually at least no. 25 reamer to the root apex

Dry the root canal with sterile absorbent points

Insert a medicated cotton pledget moistoned with an obtundent such as ZOE into

the pulp chamber

Place temporary filling such as cavit or ZOE cement over the medicated dressing

and seal the access cavity

Relieve any occlusal trauma

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Prescribe an analgesic for only if pain recurs. Premedication or post treatment

medication with antibiotics is indicated only if the patient’s condition is

medically compromised or if systemic toxicity occurs subsequently

Consult with the patient to alleviate any anxiety concerning the emergency

procedure or potential postoperative reaction and assure tha patient of your

availability

On some occasions, the dentist doesn’t have sufficient time to complete total

extirpation, therefore debridement, drying, and sealing of a medicated dressing in

the pulp chamber usually suffices. Although emergency pulpotomy isn’t as

effective as pulpectomy, it relieves the patient of pain for several days. The

patient should rescheduled as soon as possible for additional treatment.

e. Management of acute alveolar abscess

The pulp is necrotic therefore the treatment different with acute irreversible

pulpitis, local anasthesia is not needed routinely. In fact, local anesthesia is

frequently contraindicated in acutely inflamed tissue because the injection of an

infiltration anesthetic doesn’t anesthetize the tissue. Local anasthetics are

effective in tissue with a more alkaline pH and ineffective when injected into

acutely inflamed tissue. In addition, needle and infected and swollen area may

increase pain and may spread infection. Conduction anesthesia may be

administrated to reduce the pain of acute alveolar abscess, as long as the injection

route is distant from the inflamed area. A mandibular block or an infraorbital

injection can be used effectively when needed for the few isolated cases in which

some pulp vitality persist.

Place the rubber dam over the infected tooth

Complete the access opening painlessly by bracing the tooth with finger pressure

Irrigate profusely, debride the pulp chamber, but avoid forcing any solution or

debris into the periapical tissue

Using a no. 10 or no. 15 file as an explorer, locate the root canal orifices and

instrument each root canal within 1 mm of the root apex

Continue to debride and to irrigate while enlarging each root canal, but keep all

instruments and irrigants within the root canal

Frequently, a purulent exudate escapes into the chamber and indicates the root

canal is patent and draining. Relief follow quickly. If no evidence of drainage

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appears, leave the tooth open. If no evidence of drainage appears, leave the tooth

open, its root canals patent and expect relief within a short time

Advise the patient to use hot saline rinses for 3 min each hour

Prescribe analgesics or antibiotics if indicated and necessary

f. Management of referred pain

Usually comes from pulpoperiapical pathosis but the pain also can originate from

many other sources (inflamed pulp to other parts of the body, usually on the same

side and in close proximity to the tooth or from other sources that simulates the

painful symptoms of pulpoperiapical disease.

Dental pain can have its origin in trigeminal neuralgia, atypical facial neuralgia,

migraine, cardiac pain or tempuromandibular arthrosis. Other causes are

intensive radiation, systemic diseases (malaria, typhoid, influenza, anemia,

hypertension, or neurasthenia), menstrual onset, neurologic diseases of the

central nervous system, and some malignant diseases ad tumors. Other example

:

Origin Pain

Sinusitis, head cold, maxillary sinus and to the back and side of the head

Maxillary posterior teeth

Periodontal problems Pulpoperiapical painBasilar artery aneurysm produced pressure in the trigeminal nerve, otitis media, ear or the back of the head

Lower molar

Herpes zoster of the maxillary division of trigeminal

Maxillary Lateral incisor

Vascular neck pain Mandibular posterior teethTMD ToothacheMyocardial infarction, angina pectoris Left side of the mouth

Therefore endodontic emergencies won’t relieve the pain

g. Analgesic and antibioticsThe use of analgesics and antibiotics is important in endodontic emergency

treatment. Because their role is essential and supportive to the previously

described emergency procedures, every clinican should be familiar with their

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mode of action, dosage, toxicity, route of administration, indications,

contraindications, and interaction with other drugs.

Analgesics

Analgesics are pain relievers. Usually the narcotic analgesics are used to relieve

acute, severe pain, and the non narcotic (more common to use) or mild analgesics

are used to relieve slight to moderate pain. Clinician should considered the

strength of the drug, whether it is used alone or in compound form, the frequency

of use, and so on.

Mild analgesics reduce the syntehsis of prostaglandins à reduce / eliminate the

pain. The more frequently used non-narcotic analgesics are :

Aspirin

Aspirin has antiinflammatory and antipyretic properties. It’s effective for mild to

moderate pain. It can cause an anaphylactoid reaction in and allergic person or

person with gastric ulcers. It’s contraindicated for patients receiving

anticoagulant therapy, undergoing antineoplastic chemotherapy, diabetics, goty

arthritis.

Acetaminophen

It can relieve mild to moderate pain. It has lower incidence of side effects than

aspirin and is effective in smaller doses. It lacks the anti inflammatory effect of

aspirin. It is recommended for children and is available in liquid form.

Naproxen

Like diflunizal, is a long lasting analgesic. It is prescribed 275 mg tablets to be

taken twice daily.

Ibuprofen

Doses of 300-400 mg 4 times daily, is more effective for severe pain relief than

the daily therapeutic dose of aspirin, 3600 mg. Ibuprofen shouldn’t be used in

patients with a history of peptic ulcer or aspirin intolerence.

Narcotic drugs control pain better that other drugs. This drugs inhibition of

neurotransmission along central pain pathways by inhibiting the release of an

excitatory pain transmitter. Narcotic analgesics may depress the central nervous

system. They can interact adversely, sometimes fatally with alcoho,

antihistamines, barbiturate, local anesthetics, phenothiazines, tricyclic

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antidepressants, and monoamine oxidase inhibitors by enhancing the depression

of the central nervous system. All opioid analgesics may be abused and should be

prescribed with discretion. Those narcotic drugs are :

Morphine

Not administrated orally

Meperidine

50-100 mg (demerol), 1 tab q4h p.r.n

Codeine

30 mg, 1 tab q4h p.r.n

Oxycodone

5 mg, with acetaminophen 325 mg (percocet-5), 1 tab q4h p.r.n

Hydrocodone

5 mg, with acetaminophen 500 mg (vicodin), 1 tab q6h p.r.n

Dihydrocodeine

16 mg, with aspirin 356.4 mg and caffeine, 30 mg (synalgos-DC), 1 tab q4h p.r.n

Acetaminophen

300 mg, with codeine 30 mg (tylenol no. 3), 1 tab q4h p.r.n

Aspirin

325 mg, with codeine, 30 mg (empirin no. 3), 1 tab q4h p.r.n

Acetaminophen

650 mg, with propoxyphene napsylate, 100 mg (darvocet-N 100), 1 tab q4h p.r.n

Placebo is the other effect of drug administration. It can increase the analgesics

effect up to 40%.

Antibiotics

Antibiotics are life saving therapeutic agents of inestimable value. They are used

for an adjunctive treatment of acute periapical or periodontal infection.

Remember to consider patient allergy. The selection of a prescribed antibiotic

should be based on the result of susceptibility tests that indivate effectiveness

against the infecting microorganisms. The more lethal the antibiotic, the less

likely resistant microorganisms will develop to it. Practically this testing is rarely

done during endodontic emergencies because susceptibility tests require several

days to complete. Therefore it depends to the symptoms of the systemic toxicity.

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The use of antibiotics should be limited to adjunctive treatment of acute

periapical and periodontal disease and only when truly needed.

The most effective antibiotic for use in endodontic emergencies is penicillin. Its

mode of action is by inhibition of cell wall syntesis during multiplication of

microorganisms à bactericidal.

The recommended standard regiment for dental procedures is penicillin V 2 g

orally 1 hour before the procedure, then 1 g 6 hours later. In case of allergy to

penicillin, erythromycin may be prescribed : 1 mg orally 1 hour before then 500

mg 6 hours later. Penicillin is contraindicated for those who allergy with it.

Erythromycin’s mode of action is inhibition of protein synthesis and it also have

the same bacterial spectrum as penicillin V.

Other antibiotics useful for treating endodontic emergencies are :

Cephalexin (keflex) 250 – 500 mg every 6 hours

Clindamycin phosphate (cleocin HCl, 150-300 mg every 6 hours

Tetracycline hydrochloride (achromycin V) 250-300 mg every 6 hours, but it’s

the least effective of all antibiotic for endodontic emergencies

INTERAPPOINTMENT EMERGENCY

a. Causative factors

It can be related to the patient, to pulpal or periapical diagnosis, or to treatment

procedure.

b. Prevention

Procedures

Use of long anesthetic solution, complete cleaning and shaping of the root canal

system, analgesics.

Verbal instruction

Patiens should be told that there will be discomfort. It will subside in 1-2 days.

An increase in pain and swelling needs a call or a visit.

Therapeutic prophylaxis

Certain analgesics and anti-inflammatory agents will reduce post-treatment

symptoms.

c. Treatment

Previously vital pulp with complete debridement

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It doesn’t need to open the teeth. Prescription of mild to moderate analgesic is

enough.

Previously vital pulp with incomplete debridement

The working length is rechecked → the canal is cleaned with sodium

hypochlorite → placement of dry cotton pellet → temporary filling →

prescription of mild to moderate analgesic

Previously necrotic pulp with no swelling

If there is active drainage from the tooth after opening → the canal is recleaned

and irrigated with sodium hypochlorite → the canal is dried → calcium

hydroxide is placed → access is sealed

If there is no drainage → the tooth is instrumented and irrigated → calcium

hydroxide is placed → access is sealed

Long acting anesthetic and strong analgesic is helpful. Antibiotic is not

indicated.

Previously necrotic pulp with swelling

Managed by incision and drainage.

POSTOBTURATION EMERGENCY

a. Causative factor

The etiology is unknown. But, levels of pain reported after obturation tend to

correlate to levels of pain before the appointment.

b. Treatment

-Retreatment → when prior treatment hasn’t been adequate

-Analgesic prescribtion → when patient reports severe pain, but no evidence of

acute apical abscess and root canal treatment is well done

III. Restoration After Endodontic Treatment

It’s better to give permanent restoration immediately after obturation. However,

in some cases we should delay the permanent restoration because of some

reasons:

a. The bad prognosis because of complicated root canal system, uncompleted

obturation, fractures of instrument, and perforation.

b. If the tooth is indicated as bridge supporter.

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c. If we predict there is a possibility if failure and the only one solution is

extraction, we have to delay the PR.

During the delay of permanent restoration, we should put temporary restoration.

Material for permanent restoration can be direct or indirect. We can use direct

restoration if the remaining tooth structure is large enough.

Criteria of Temporary Restoration:

a. Enclose the crown tightly

b. Protect the tooth until PR is given

c. Easy to be placed and removed

d. Have good esthetic

Types of Temporary Restorative Material:

Zinc Oxide Eugenol

a. It’s not too strong, but have good hermetic

b. Long setting time à make deformation

Cavit

a. ZOE polyvinyl

b. Hydrophilicà set in wet condition

c. Easy to be used and has good hermetic

d. Low strength and low wear protection

e. Short time used

IRM

a. Intermediate Restorative Material

b. Higher protection of wear

TERM

a. Composite with special formula for endodontic treatment

b. Has polymerization shrinkage and water absorption

c. Same tightness with cavit buts stronger and have higher wear protection

IV. Local Anesthesia

Local anesthetics are divided into amide and ester classes. Amide and ester were

both used, but esters lost their favor after reports of increased sensitization.

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IV.1. Lidocaine

Lidocaine is the most versatile and commonly used amide anesthetic. In 1943,

lidocaine was the first drug of the amino amide type to be introduced into clinical

practice, and its rapid onset and moderate duration of action ensure its

widespread use today. Lidocaine is available in solutions ranging from 0.5 to 4

percent; however, no studies have compared the efficacy of the different

solutions. Lidocaine at 2 percent concentration may be particularly useful when a

smaller injected volume is indicated.

IV.2. Mepivacaine and Prilocaine

Mepivicaine (Carbocaine®) and prilocaine (Citanest®) have much less

vasodilative qualities and hence can be used without the epinephrine

vasoconstrictor. The advantage to this is that these anesthetics can be used more

safely in patients who are taking medications which may interact negatively with

the vasoconstrictor. Carpules that do not contain vasoconstrictor do not

contain preservatives either.  This is an important point, since it is most

frequently the preservatives, and not the anesthetics themselves which play a

roll in allergic reactions. Most anesthetic solutions are sold with added

vasoconstrictor.  Only two, mepivicaine and prilocaine are sold with or without

vasoconstrictor.

IV.3. Bupivacaine and Etidocaine

Bupivacaine provides an intermediate onset and a longer duration of action. It is

especially useful when prolonged anesthesia is needed and epinephrine is

contraindicated (i.e., for joint injections and digital nerve blocks). Other

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anesthetics in the amide group can be used in the office but are commonly

reserved for spinal and regional anesthesia. The most frequent use of Bupivicaine

is to prevent post-operative pain after surgical procedures.  Some dentists will

inject a carpule of Bupivicaine after an extraction in order to delay the onset of

pain for up to nine hours.  This delay effectively reduces the period of severe post

operative discomfort  which generally tapers off during the first 12 hours post op.

IV.4. Articaine

Articaine is the newest addition to the local anesthetic arsenal and was approved

by the Food and Drug Administration in April 2000. Articaine has become the

local anesthetic of choice in most countries into which it has been introduced.   I

have found that it produces profound anesthesia (in most patients) when used as

an infiltration (field block) for mandibular premolars and anterior teeth instead of

the traditional mandibular nerve block..  With clinical reports of profound

anesthesia, fast onset, and success in difficult-to-anesthetize patients, Septocaine

has become the most used dental anesthetic brand name in the US, although

lidocaine still remains the most used type of anesthetic.

Articaine and prolonged numbness and paresthesia

Unfortunately, one complication concerning the use of articaine has arisen. 

There have been persistent reports of unexplained paresthesia. The most

common link with articaine and paresthesia was administration of mandibular

nerve block injections.  For this reason a number of dentists have abandoned the

use of articaine for mandibular nerve blocks, but still use it for infilatration

anesthesia (field blocks) of mandibular anterior teeth and bicuspids.

IV.5. Initial management

a. Psychologic approach

Control is achieved by obtaining and maintaining the upper hand.

Communication is accomplished by listening and explaining what is to be done

and what the patient should expect

Concern is shown by verbalizing awareness of the patient’s fear.

Confidence is expressed in body language and in professionalism → give

patient’s confidence in the management, diagnostic, and treatment skills

b. Painless injection

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Master injection technique that are almost painless → relaxes the patient and

raises the pain threshold

Topical anesthetic-when a topical anesthetic gel is used, a small amount on a

cotton-tipped applicator is placed on the dried mucosa for 1-2 minutes before the

injection.

Needle insertion-initially, the needle is inserted gently into the mucosal tissue.

Small-gauge needles-as a recommendation, a 27-gauge needle is suitable for most

conventional dental injections

Slow injection- it is effective to decrease pressure and patient discomfort during

injection. Slow deposition permits its gradual distribution into the tissues.

Solution deposition should take approximately 1 minute per cartridge.

Two stage-injection-initial very slow administration of a quarter cartridge of

anesthetic under mucosal surface then full depth cartridge at the target site.

c. When to anesthetize

Preferably, anesthesia should be given at each appointment. Although for the

necrotic pulps and periapical lesions (there may be vital tissue in the apical few

millimeters of the canal)

d. Additional pharmacologic therapy

Sedation (intravenous, oral, inhalation) may enhance local anesthesia.

IV.6. Mandibular anesthesia

The most commonly used agent is 2% lidocaine with 1:100,000 epinephrine. It is

safe and effective.

Contraindication: patients taking tricyclic antideppresant or nonselective

adregenergic blocking agent or patients with moderate to severe cardiovascular

disease

a. Related factors

Lip numbness-numbness usually occurs in 5-7 minutes.

Onset of pulpal anesthesia-pulpal anesthesia usually occurs in 10-15 minutes.

Duration-anesthesia usually persists for approximately 2 ½ hours.

Success-the incidence of successful mandibular pulpal anesthesia tends to be

more frequent in molar and premolar

b. Alternative techniques

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Increasing the volume-increasing the volume of anesthetic doesn’t increase the

success rate of pulpal anesthesia with the inferior alveolar nerve block.

Alternative solution

(1) 2% mepivacaine with 1:20,000 levonordefrin

(2) 4% prilocaine with 1:200,000 epinephrine

(3) Solutions without vasoconstrictor (3% mepivacaine plain and 4% prilocaine

plain)

Infiltration injection-labial or lingual infiltration injections used alone are not

effective for pulpal anesthesia

Long-acting anesthetic-usage of bupivacaine and etidocaine → provide prolonged

analgesic period, indicated when post operative pain is anticipated

Pain and inflammation-patients with symptomatic pulpal or periapical pathosis

(or who are anxious) present additional anesthesia problems.

IV.7. Maxillary anesthesia

a. Anesthetic agent

2% lidocaine with 1:100,000 epinephrine

b. Related factors

Anesthesia is more successful in maxilla than in the mandible. The most common

injection for maxillary teeth is infiltration

Lip numbness-usually occurs within few minutes.

Success and failure-infiltration results in a high incidence of successful pulpal

anesthesia

Onset of pulpal anesthesia-pulpal anesthesia usually occurs in 3-5 minutes

Duration-duration of pulpal anesthesia will be:

In anterior teeth : decline after 30 minutes, most losing anesthesia by 60 minutes

In premolar & first molar : losing anesthesia by 45-60 minutes

c. Alternative techniques

Volumes of solution-increasing the volume increases the duration of pulpal

anesthesia.

For anterior teeth and premolar : two cartridges directly or give one initially and

inject another 30 minutes later

For first molar : two cartridges directly

Alternative solution

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Prilocaine, mepivacaine, lidocaine (all with vasoconstrictor) act similarly.

Solutions without vasoconstrictor (3% mepivacaine plain and 4% prilocaine

plain) provide short duration of anesthesia,

Other technique

The posterior superior alveolar (PSA) block anesthetizes the second and third

molars and usually the first molar. It is indicated when all molar teeth require

anesthesia.

The infraorbital block results in lip numbness. It usually anesthetizes the

premolars. Duration is less than 1 hour.

The second division block usually anesthetizes pulps of molars and some second

premolars

IV.8. Anesthesia difficulties

a. The anesthetic solution may not penetrate to the sensory nerves that innervate the

pulp, especially in the mandible.

b. Local tissue or nerve changes occur because of inflammation.

Lowered pH of inflamed tissue → reduces the amount of the base form of the

anesthetic available to penetrate the nerve membrane

Hyperalgesia theory: nerves arising in inflamed tissue alter resting potentials and

decreased excitability thresholds

c. Patients in pain often are afraid → lower their pain threshold.

IV.9. Supplemental anesthesia

Indications

It is used if the standard injection isn’t effective. It is done if the patient doesn’t

exhibit classic signs of soft tissue anesthesia.

Anesthetic agents

2% lidocaine with 1:100,000 epinephrine

a. Intraosseus anesthesia

Placement of local anesthetic directly into the cancellous bone adjacent to the

tooth. One part is a slow-speed handpiece-driven perforator, which drills a small

hole through the cortical plate. The anesthetic solution is delivered into

cancellous bone through a matching 27-gauge ultrashort injector needle

Technique The area of perforation and injection is on a horizontal line of the

buccal gingival margins of the adjacent teeth and a vertical line that passes

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through the interdental papilla distal to the tooth to be injected. A point

approximately 2 mm below the intersection of these lines is selected as the

perforation site.

The soft tissue is first anesthetized by infiltration. The perforator is placed

through the gingiva perpendicular to the cortical plate. With the point gently

resting against bone, the handpiece is activated in a series of short

bursts, using light pressure, until there is a "breakthrough" into cancellous bone

(taking approximately 2 to 5 seconds).

b. Periodontal ligament injection

A standard syringe or pressure syringe is equipped with a 30-gauge ultrashort

needle or a 27-or a 25-gauge short needle. The needle is inserted into the mesial

gingival sulcus at a 30-degree angle to the long axis of the tooth. The needle is

positioned with maximum penetration (wedged between root and crestal bone).

Heavy pressure is SLOWLY applied

on the syringe handle for 10-20 seconds (conventional syringe),

Back pressure is important. If there is no back-pressure (resistance) -that is, if the

anesthetic readily flows out of the sulcus, the needle is repositioned, and the

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technique repeated until back-pressure is attained. The injection is then repeated

on the distal surface.

c. Intrapulpal injection

Indication when intraosseous and periodontal ligament injections, even when

repeated, do not produce profound anesthesia. Pain persists when the pulp is

entered.

Advantage if the injection is given under back pressure, onset will immediate

and no special syringe or needles are required.

Disadvantage if the needle is inserted directly into a vital and very sensitive

pulp, the injection may be very painful. Duration of anesthesia, once attained, is

short (about 20 minutes).

Technique

An injection into each canal after the chamber is unroofed. A standard syringe is

usually equipped with a bent short needle. The needle is positioned in the access

opening and then moved down the canal, while slowly expressing the anesthetic,

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Maximum pressure is then applied slowly on the syringe handle for about 10

seconds.

IV.10. Anesthetic management of pulpal or periapical disease

a. Irreversible pulpitis

General consideration

Conventional anesthesia, using primary techniques, is administered. Upon access

opening or when the pulp is entered, pain results because not all sensory nerves

have been blocked. A useful procedure is to pulp test the tooth with cold or an

electric pulp tester before the access is begun. If the patient responds, an IO or

PDL injection is given.

Mandibular posterior teeth

A conventional inferior alveolar injection is administered, usually in conjunction

with a long buccal injection. Because of the high failure rate of anesthesia for

these teeth, an IO or PDL injection is routinely administered before access is

begun. If pain is felt, the IO or PDL injection may be repeated or an IP injection

is given if the pulp is exposed.

Mandibular anterior teeth

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An inferior alveolar injection is given. If pain is felt, an IO injection is

administered. If this is unsuccessful, an IP injection is added.

Maxillary posterior teeth

The injection site may be a PSA block for molars. Infiltration of 0.5 ml of

anesthetic over the palatal apex enhances pulpal anesthesia. If pain is felt during

the access, an IO or PDL injection is administered.

Maxillary anterior teeth

Anesthetic is administered initially as a labial infiltration and, occasionally, as a

palatal infiltration for the retainer.

b. Symptomatic pulp necrosis

For the mandible, an inferior alveolar nerve block and long buccal injection are

administered.

For maxillary teeth, if no swelling is present, anesthesia is given with a

conventional infiltration or block. If soft tissue swelling is present (cellulitis or

abscess), a regional block plus infiltration on either side of the swelling is

administered.

If conventional injections don’t provide adequate anesthesia. IO, PDL, or IP

injections are contraindicated. Although effective for vital pulps, these injections

are painful and ineffective with apical pathosis.

c. Asymptomatic pulp necrosis

Conventional injections are usually administered: inferior alveolar nerve block

and long buccal injection for mandibular teeth and infiltration (or PSA block) in

the maxilla.

Rarely, there may be some sensitivity during canal preparation that requires an IO

or PDL injection. IP injection is

not indicated because bacteria and debris may be forced periapically.

V. Root Canal Disinfection

Root canal disinfection is the destruction of pathogenic microorganisms by

capturing and removing pulp tissue, debris cleaning, widening of root canals with

biochemical means, and cleaning it with irrigation. Root canal disinfection is

along with root canal medication.

V.1. Root canal flora

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a. Microbial flora of root canal may consist of organisms that can live on dead pulp

tissue, which is a saprophyte that can grow in an environment with low oxygen

tension, and can survive in environments with limited food.

b. One of the endodontic problem is to eliminate gram positive organisms, because

these organisms are most abundant, consisting of streptococci and staphylococci.

There are also a small amount of enterococcus but they are resistance.

There are 4 factors that cause tooth susceptible to infection, and these factors can

also inhibit healing. These factors are:

a. Trauma

b. Devitalization Tissue→ If present in root canals or periapical tissue, it would

interfere disinfection or repair.

c. Death Spaces → For maximum effect, medikamen must come into contact with

microorganisms in the root canal.

d. Accumulated Exudate → So the exudate must be removed.

V.2. Intracanal medicament

Terms of root canal disinfection:

a. Must be germisida and fungicides.

b. Not irritate the periapical tissue.

c. Remain stable in solution,

d. Have the effect of antimicrobial.

e. Have low surface tension.

f. Not interfere periapical tissue repair.

g. Must be able to be non-activated in culture medium (medium biakan).

h. Should not induce an immune response

V.3. Essential oils

The essential oil is a weak disinfectant.

Eugenol → a chemical essence of clove oil and have a relationship with phenol.

A bit more irritating, and is antiseptic. Eugenol inhibits interdental nerve

impulses.

V.4. Phenol collections

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a. Phenol

Melted Phenol (carbolic acid) consists of 9 parts phenol and 1 part water, and has

a distinctive smell of coal.

It is a protoplasmic poison and causes soft tissue necrosis.

b. Para-chlorophenol

This compound is a replacement product of phenol with chlorine replaces one of

atom hydrogen atom (C6H4HCl).

This watery solution destroys various microorganisms that are usually found in

infected root canals and goes deeper into the dentin tubule compared with the

camphored chlorophenol.

c. Camphored Para-Chlorofenol

Consists of two parts of para-chlorophenol and three parts of camphorgram.

Camphor is useful as a tool and a diluent and reducing the irritating effect that

belongs to the pure para-chlorophenol, and also extending the antimicrobial

effect.

Camphored steam chlorophenol passes through the apical foramen and has the

effect of medium irritation.

d. Formokresol

This material is a combination of formalin and cresol with a ratio of 1 : 2 or 1 : 1.

Formalin is a powerful disinfectant which joined with albumin to form a

substance that cannot be dissolved and cannot become rotten.

Formokresol is a non-specific bactericidial medikamen and highly effective

against aerobic and anaerobic organisms found in the root canal, but it is high

degree irritating materials.

It causes necrosis which lasted until 2-3 months.

e. Glutaraldehida

Colorless oil that soluble in water and has a slightly acid reaction and also a

powerful disinfectant and fixative.

Providing recommended in low doses (2%) as a drug intrasaluran.

f. Cresatin

Also known as metakresilasetat, this material is a clear liquid, stable, oily and not

very volatile.

Has antiseptic properties and ease the pain.

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Cresatin antimicrobial effect is smaller than the formokresol or camphored para-

chlorophenol, but not so irritating.

g. Calcium Hidroxide

The effect of antiseptic may be related to its high pH and influenced in the

melting of the necrotic pulp tissue.

Calcium hydroxide caused a significant rise in dentinal pH when the compounds

are placed at circumpulpal root canals.

Calcium hidroxide paste best is best used as a medikamen intracanal if there is a

delay too long between visits, because this material remains to be efficacious

(manjur) during root canals.

h. N2

Contains formaldehyde as the main element, expressed both as intracanal

medikamen or as siler.

Contains eugenol and fenilmerkury and sometimes additional materials such as

lead, corticosteroids, antibiotics, and perfumes.

Antibacterial effect of N2 is only brief and disappear in about a week or ten days.

V.5. Halogen

a. Sodium Hypochlorites

Steam sodium hypochlorite is bactericidal, watery para-chlorophenol and

chompered chlorophenol is bacteriostatic.

Because the activity of sodium hypochlorite is great but brief, this this compound

is better applicated to root canal every two days, evenhough this material is

slightly irritating.

b. Yodida

Highly reactive, combines with protein in loose binding so that the penetration is

not disrupted.

It would probably destroy microorganisms by forming salt that harmful

microorganisms life.

The antibacterial effects is short while and this material is the least irritating

medikamen.

c. Quaternary Ammonium Compound

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"Quats" is a compound that lowers the surface tension of the solution, due to the

quartenary ammonium compounds are positively charger and the microorganisms

are negatively charged, there will be formed an activation surface with

coumpound attached to the microorganisms.

VI. Analgesics

In endodontic treatment, is usually required analgesic drugs as pain relievers.

Analgesics may be classified as follows:

6.1. Non-Opioid 

a. Non-Steroid Anti-Inflammatory (NSAIDs) Nonsteroidal anti-inflammatory drugs

(NSAIDs) 

Is a class of drugs that are pharmacologically active compounds that work has

inhibited the production of prostaglandins. The drug is used for pain in acute or

chronic inflammatory. These drugs have the characteristics to relieve pain, fever,

and inflammation. 

NSAIDs are believed to have therapeutic effects through inhibition of

cyclooxygenase enzyme that is an enzyme that affects the synthesis of

prostaglandins from arachidonic acid and tromboxsan. So terjaid inhibition of

production of proinflammatory prostaglandins, especially prostaglandin E2

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(PGE2). When this has been found in the enzyme cyclooxygenase 2

(COX2). Drugs that inhibit only the COX2 enzyme without inhibiting the enzyme

cyclooxygenase 1 (COX1) work more specifically, the common side effects of

drugs of this class of gastric irritation and ulceration can be prevented. 

NSAID medicines are classified as follows: 

Carboxylic acid 

1) Acetic Acid 

Phenylacetic acid derivative: Diclofenac, Fenklofenak 

Asetat-inden/indol acid derivatives: Indomethacin, Sulindak, Tolmetin 

2) Acid derivatives Salicylates: Aspirin, Benorilat, Diflunisal, Salsalat 

3) Propionic acid derivatives: Acid tiaprofenat, Fenbuten, Fenoprofen, Flurbiprofen,

Ibuprofen, Ketoprofen, Naproksen 

4) Acid derivatives Fenamat: Mefenamic acid, Maklofenamat 

Acid enolate 

1) Derivatives Pirazolon: Azapropazon, phenylbutazone, Oksifenbutazon 

2) Oksikam derivatives: piroxicam, Tenoksikam 

Here is an explanation of NSAID drugs are often used in dentistry: 

Aspirin (acetyl salicylic acid) 

Pharmacokinetics: absorption of oral administration, aspirin is absorbed

rapidly, partly from the stomach, a portion of the upper small intestine. The

highest concentration of approximately 2 hours after administration. Absorbsinya

speed depends on several factors, mainly the speed of tablet disintegration and

dissolution, the pH at the mucosal surface and gastric emptying time. Distribution

once absorbed, aspirin would be spread throughout the body surface and the

fluid between cells. 50-90% of aspirin bound to plasma proteins, primarily

albumin.  biotransformation biotransformation of aspirin occurs in many tissues,

especially in a system of liver microsomes and mitochondria. Excretion

excreted through the kidneys (at most) in the form metabollit 

Pharmacodynamic: used to relieve mild to moderate pain, central (works on

hypothalamus) or peripheral (inhibit the formation of prostaglandins in the

inflammation and prevent the sensitization of pain receptors to mechanical or

chemical stimuli 

Dosage: 325-650 mg orally every 3-4 hours (adults) 

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Side effects: gastrointestinal disorders such tools dyspepsia, nausea and

vomiting.Aspirin allergy can cause skin redness, edema of the larynx, asthma,

anaphylactic reactions. Effects on the CNS in the form of dizziness, blurred

vision, a lot of sweat, drowsiness, restlessness, vertigo, etc. 

Derivatives Pyrazolon 

Included in the pyrazolone: antipirin (fenazone), aminopropin (amidopirin),

fenilbutazone, and their derivatives. 

Pharmacodynamic: analgesic, antipyretic and anti-inflammatory (stronger than

aspirin). Not interfere with acid-base balance 

Pharmacokinetics: antipirin to measure the amount of water in the

body. Aminopirin experiencing metabolism by enzymes in liver

microsomes. Only 3% aminopirin original form excreted in urine 

Side effects: agranulotosis, aplastic anemia and thrombocytopenia, the drug is to

form nitrosamines which are carcinogenic 

:0,3-1 g dose 3 times a day 

Fenoprofen 

Pharmacodynamic: anti-inflammatory, analgesic, antipyretic 

Pharmacokinetics: rapidly absorbed through oral administration, the highest

concentration in plasma is reached within 90 minutes, tightly bound in plasma

proteins, excreted through urine 

Side effects: gastrointestinal disorders such as constipation, nausea, vomiting,

stomach bleeding. 

Dose: 600 mg 4 times daily, after satisfactory, the dose adjusted 

Ibuprofen 

Efficacy and side effects similar to fenoprofen. Dose of 400 mg 4 times

daily.Contraindicated in pregnant and lactating mothers 

Mefenamic acid 

Pharmacodynamic: acute and chronic pain who are, are more tosik 

Side effects: irritation of the stomach, intestinal colic and diarrhea. 

Contraindications: patients with peptic gastric disorders, diarrhea, pregnant

women and asthma 

Dose: 250 mg every 6 hours for no more than 7 days 

Pengguanaan to be oriented on nonopioid oral, some such patients, small children

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or patients who have intermaksilari fixation after maxillofacial surgery or trauma,

can not swallow tablets capsule atu. For these patients, liquid / liquid of

acetaminophen or ibuprofen can be considered. 

For rare cases, such patients can not receive medication by mouth Parenteral

(ketorolac) or rectal (acetaminophen, aspirin). 

b. Acethaminophen 

Acetaminophen is an antipyretic analgesic drug which is used as a substitute

asprin out because of stomach problems or other contraindications. 

Indications: Provides analgesic effects, the field of dentistry is widely used after

dental surgical procedures, are also commonly used after extraction of third molar

teeth. These drugs also provide anti-inflammatory effects, although not sepoten

aspirin. Acetaminophen shows positive effects to bear the pain until pemakaina

1000 mg. 

Pharmacodynamic: similar to aspirin, relieve pain mild - moderate

Acetaminophen has analgesic and antipyretic effects are equivalent to

aspirin. Just as with other NSAID drugs, acetaminophen is also work by

inhibiting prostaglandin synthesis.That distinguishes only diinhibit spectrum of

different COX enzymes.Acetaminophene also been proven to work more actively

than spirin in the CNS, whereas the less active peripheral works. It's just anti-

inflamasinya work was minimal, this is due perokside produced by leukocytes in

inflamed tissue. Perokside highly reactive with acetaminophen, so the work

acetaminophenpun will be reduced. 

Pharmacokinetics: Absorbed rapidly and completely through the gastrointestinal

tract. High concentrations in plasma reached within ½ hour. Experiencing

metabolism in the liver by enzin microsomes and secreted through the

kidneys.These drugs can be easily absorbed by the small intestine when given

orally. Well distributed in body tissues and fluids tubuh.sedangkan through

elimination occurs through the kidneys by glomerular filtration and secretion in

proximal tubule. 

Side effects: Side effects caused by this drug caused by its relationship with

alcohol and drug overdose. When given an overdose of acetaminophen poisoning

will cause liver and kidney damage. In some patients, allergic reactions can also

occur, such as skin Eruption. Rare cases is neutropenia, thrombocytopenia, and

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pancytopenia. The combination of these drugs with alcohol consumption can

cause liver disfunction because berfifat hepatotoksi. Side effects of these drugs is

lower than aspirin, does not cause allergies and irritation of the stomach. 

Dose: 300 mg-1 g per time with max dose of 4 g per day for adults: 150-300 mg /

dose max times with 1.2 g / day for children aged 6-12 years 

c. Corticosteroid

Function glucocorticosteroids suppress pain because of acute inflammation by

pressing vasodilatation, PMN migration and phagocytosis, and inhibit the

formation arakidonik acid that functions in the mechanism of pain.

Postoperative pain or flare-ups can be caused by inflammation and infection that

occurs in periapeks, as we have seen in response to irritants, inflammatory

mediators such as prostaglandins, leukotrienes, bradykinin, pAF, substance-P,

and others issued to surrounding tissue, which can cause vasodilation and

increased vascular permeability that can cause edema.

Mechanism of action:

Corticosteroids work by affecting the rate of protein synthesis. Hormone

molecule enters the network through the plasma membrane by passive diffusion

in the target tissue, and then react with a specific receptor protein in the cell

cytoplasm and form a complex network of receptor-steroid. These complex

changes conformation, and then move toward the nucleus and binds to

chromatin. These bond synthesis stimulates the transcription of RNA and specific

proteins. Induction of protein synthesis is an intermediary for the physiological

effects of steroids. .

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6.2. Opioid

Opioid analgesics are added to nonopioid to regulate rasasakit from medium to

severe or do not respond to nonopioid.

Limit dose used, based on physical samping.pertahanan effects and tolerance of

the body can occur virtually in all patients using opioid analgesics in the long

term.

Opioid analgesics, including both pure agonists (such as codeine and oxycodeine)

and agonist / antagonist (such as pentazocine and butorphanol)

Severe pain should be treated with a combination of nonopioid and opioid (such

as morphine or hydromorphone)

Adjuvants (substances added to a drug to add the power of component) agent

(anticonvulsant: an agent that inhibits seizures, or tricyclic antidepressan) can be

added also in accordance with the indication).

For patients who can not swallow tablets or capsules in a liquid formulation can

be useful opioids (codeine, hydrocodone, oxycodone).

Opioids and phenothiazines (chlorpromazine) is known to produce CNS

depression, including respiratory depression.

Aspirin and NSAIDs are used to reduce pain to pathological processes (pulpitis,

dentoalveolar, abscess)

Opioids for dentistry:

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a. Morphine and opium alkaloids

Pharmacodynamic: is highly selective and not accompanied by loss of function

snsorik. Usefulness based on 3 factors: elevated pain threshold, affect the

emotions, facilitate sleep (increased pain threshold)

Pharmacokinetics: morphine can not penetrate intact skin, but can penetrate the

oral mucosa. Effects of oral administration is lower than parenteral

administration.Morphine excretion through the kidneys, a fraction of faeces and

sweat

Side effects: addiction restlessness, rapid breathing, yawning, anorexia, etc.

b. Meperidine

Pharmacodynamic: same as morphine, faster and shorter tenure

Pharmacokinetics: good absorption after oral administration, maximum plasma

concentrations achieved within 1-2 hours. Metabolism in the liver

Side effects: dizziness, sweating, dry mouth, nausea and feeling weak

Dose: 50 mg (tablets) oral administration

c. Methadone

Pharmacodynamic: same as morphine

Pharmacokinetics: oral administration to work 20-30 minutes. Well absorbed in

the intestine. Quick out dri blood and accumulate in the lungs, liver, kidney,

spleen, and a small entrance into the brain

Dose: tablets 5, 7.5 and 10 mg (oral)

Side effects: dizziness, drowsiness, sweating and vomiting

VII. Antibiotics

VII.1. Contraindication

Healthy patients without systemic signs and symptoms of infection but with

symptomatic pulpitis, symptomatic apical periodontitis, draining sinus tract, or

localized swelling

VII.2. Prophylactic antibiotics for medically compromised patients

Patients who are at risk of metastatic infection after a bacteremia must receive a

regimen of antibiotics that either follows the recommendations of the American

Heart Association (AHA) or is determined in consultation with the patient's

physician.

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The AHA recommends the use of antibiotics to protect against endocarditis for

canal instrumentation beyond the apex, for endodontic surgery and for anesthesia

delivered via the periodontal ligament.

Patients considered to be at risk include

immunocompromised/immunosuppressed patients, insulin-dependent (type I)

diabetic patients, patients who have had joint replacement in the past 2 years, and

those with previous joint infections, malnourishment, and hemophilia

VII.3. Antibiotics used in treatment

Antibiotic should be prescribed in conjunction with the appropriate endodontic

procedure when there is systemic involvement, a persistent infection, or a

spreading infection.

Signs and symptoms of systemic involvement and spread of infection include:

fever (>38' C), malaise, cellulitis, progressive abscess, and unexplained trismus,

alone or in combination → antibiotic

should be given as an addition to debridement and drainage or extraction when

indicated.

VII.4. Selection of an antibiotic regimen

a. Penicillin VK: first choice (it has remained effective against most of the

facultative and strict anaerobes commonly found in endodontic infections).

Penicillin is inexpensive, has low toxicity, but approximately 10% of the

population may be allergic to this medication. For penicillin prescription, an

adequate blood level must be obtained.

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DOSAGE An initial oral loading dose of 1000 mg of penicillin VK is followed

by 500 mg every 6 hours for 7 days.

b. Amoxicillin has a broader spectrum than penicillin VK that includes bacteria not

usually found in endodontic infections.

DOSAGE An oral loading dose of 1000 mg is followed by 500 mg every 8 hours

for 7 days.

c. Metronidazole against anaerobes but doesn’t have activity against aerobes or

facultative anaerobes.

The addition of metronidazole to penicillin for combined therapy is indicated if

the patient's condition is not improving after 72 hours. The patient should

continue to take the prescribed penicillin to against aerobes or facultative

anaerobes.

DOSAGE 500 mg every 6 hours for 7 days

d. Clindamycin against many Gram-positive and Gram-negative microorganisms

including both facultative and strict anaerobes. It is a good (but expensive)

alternative to penicillin and is recommended for patients allergic to penicillin.

DOSAGE 300 mg loading dose followed by 150 to 300 mg every 6 hours for 7

days.

e. Clarithromycin and azithromycin prescribed for patients allergic to penicillin

with relatively mild indications for systemic antibiotic therapy.

DOSAGE Clarithromycin may be given with or without meals in a dose of 250

to 500 mg every 12 hours for 7 days

DOSAGE Asithromycin should be taken 1 hour before meals or 1 hour after

meals. A loading dose of 500 mg is followed by 250 mg daily for 5 to 7 days.

VIII. Considerations in Endodontic

The process of case selection and treatment planning begins after a clinician has

diagnosed an endodontic problem. The clinician must determine if the patient’s

oral health needs are best met by providing endodontic treatment and maintaining

the tooth or by advising extraction. Questions concerning tooth retention and

possible referral can be answered only after a complete patient evaluation. The

evaluation must include assessment of medical, psychosocial, and dental factors

as well as a consideration of the relative complexity of the endodontic procedure.

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Although most medical conditions do not contraindicate endodontic treatment,

some can influence the course of treatment and require specific modifications.

The American Society of Anesthesiologists (ASA) Physical Status Classification

was devised in 1941 and revised to its present form in 1983. The ASA website

lists the following:

ASA I- Normal, healthy patient; no dental management alterations required.

ASA II- A patient with mild systemic disease that does not interfere with daily

activity or who has significant health risk factor (e.g., smoking, alcohol abuse,

gross obesity); may or may not need dental management alterations.

Examples: Stage I or II hypertension, type 2 diabetes, allergy, well-controlled

asthma.

ASA III- A patient with moderate to severe systemic disease that is not

incapacitating but may alter daily activity; may have significant drug concerns;

may require special patient care; would generally require dental management

alterations.

Examples: Type 1 diabetes, stage 3 hypertension, unstable angina pectoris,

recent myocardial infarction, poorly controlled congestive heart failure, AIDS,

chronic obstructive pulmonary disease, hemophilia.

ASA IV- A patient with severe systemic disease that is a constant threat to life;

definitely requires dental management alterations; best treated in special facility.

Example: Kidney failure, liver failure, advanced AIDS.

The ASA classification remains the most widely used assessment method for

preanesthetic patients despitebsome inherent limitations to its use as a

perioperative risk predictor. This is a generally accepted and useful guide for

preoperative assessment of relative risk. However, the prudent clinician should

also take into account other factors not considered in the classification scheme,

such as age, obesity, and skill of the health care provider.

COMMON MEDICAL FINDINGS THAT MAY INFLUENCE

ENDODONTIC TREATMENT PLANNING

VIII.1.Pregnancy

Although pregnancy is not a contraindication to endodontics, it does modify

treatment planning. An extensive body of literature exists concerning the use of

radiographs and drugs while treating pregnant patients. Protection of the fetus is

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a concern when administration of ionizing radiation or drugs is considered. Of all

the safety aids associated with dental radiography, such as high-speed film,

digital imaging, filtration and collimation, the most important is the protective

lead apron with thyroid collar.

Drug administration during pregnancy is a controversial subject. A major concern

is that a drug may cross the placenta and be toxic or teratogenic to the fetus. In

addition, any drug that is a respiratory depressant can cause maternal hypoxia,

resulting in fetal hypoxia, injury, or death. Ideally, no drug should be

administered during pregnancy, especially during the first trimester. If a specific

situation makes adherence to this rule impossible, then that clinician should

review the appropriate literature and discuss the case with the physician and

patient.

Further considerations exist during the postpartum period if the mother breast

feeds her infant. Although most drugs are only minimally transmitted from the

maternal serum to the breast milk and the infant’s exposure is not significant, the

clinician should avoid using any drug known to be harmful to the infant. A

dentist should consult the responsible physician before using any medications for

the nursing mother. Alternative considerations include using minimal dosages of

drugs, having the mother bank her milk before treatment, having her feed the

child before treatment, or suggesting the use of a formula for the infant until the

drug regimen is completed.

Partial List of Drugs Usually Compatible with Breast Feeding

Acetaminophen

Many antibiotics

Aspirin (should be used with caution)

Codeine

Ibuprofen

Insulin

Quinine

Thyroid medications

In terms of treatment planning, elective dental care is best avoided during the first

trimester because of the potential vulnerability of the fetus. The second trimester

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is the safest period in which to provide routine dental care. Significant surgical

procedures are best postponed until after delivery.

VIII.2.Cardiovascular Disease

Patients with some forms of cardiovascular disease are vulnerable to physical or

emotional stress that may be encountered during dental treatment, including

endodontics. Patients may be confused or ill informed concerning the specifics of

their particular cardiovascular problem. In these situations, consultation with the

patient’s physician is mandatory before the initiation of endodontic treatment.

Patients who have had a myocardial infarction (i.e., “heart attack”) within the

past 6 months should not have elective dental care. This is because patients have

increased susceptibility to repeat infarctions and other cardiovascular

complications and may be taking medications that could potentially interact with

the vasoconstrictor in the local anesthetic. In addition, vasoconstrictor should not

be administered to patients with unstable angina pectoris or to patients with

uncontrolled hypertension, refractory arrhythmias, recent myocardial infarctions

(less than 6 months), recent stroke (less than 6 months), recent coronary bypass

graft (less than 3 months), uncontrolled congestive heart failure, and uncontrolled

hyperthyroidism. Vasoconstrictors may interact with some antihypertensive

medications and should be prescribed only after consultation with the patient’s

physician. For example, vasoconstrictors should be used with caution in patients

taking digitalis glycosides (e.g., digoxin) because the combination of these drugs

could precipitate arrhythmias. Local anesthetic agents with minimal or no

vasoconstrictors are usually adequate for nonsurgical endodontic procedures.

A patient who has a heart murmur as a result of a pathologic condition may be

susceptible to an infection on or near the heart valves, which is caused by a

bacteremia. This infection is called infective or bacterial endocarditis and is

potentially fatal. Patients who have a history of murmur or mitral valve prolapse

with regurgitation, rheumatic fever, or a congenital heart defect must be given

antibiotic therapy prophylactically before endodontic therapy to minimize the

risk of bacterial endocarditis. Because the American Heart Association

periodically revises its recommended antibiotic prophylactic regimen for dental

procedures, it is essential for the clinician to stay current concerning this

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important issue. A low compliance rate exists among at-risk patients regarding

their use of the suggested antibiotic coverage before dental procedures. Therefore

the clinician must question patients concerning their compliance with the

prescribed prophylactic antibiotic coverage before endodontic therapy. If the

patient has not taken the antibiotic, the procedure must be delayed.

Patients with artificial heart valves are considered highly susceptible to bacterial

endocarditis. Therefore consulting this patient’s physician regarding antibiotic

premedication is essential. Some physicians elect to administer parenteral

antibiotics in addition to or in place of the oral regimen. The coronary artery

bypass graft is a common form of cardiac surgery. Ideally, vasoconstrictors

should be minimized during the first 3 months after surgery to avoid the

possibility of precipitating arrhythmias. Ordinarily these patients do not require

antibiotic prophylaxis after the first few months of recovery unless there are other

complications. The clinician can play an important role in the detection of

hypertension. The clinician may be the first to detect an elevated blood pressure.

Further, patients receiving treatment for hypertension may not be controlled

adequately because of poor compliance or inappropriate drug therapy. Abnormal

blood pressure readings become the basis for physician referral. Few conditions

exist in which there is a possibility that dental treatment could seriously injure or

even result in the death of a patient. However, acute heart failure during a

stressful dental procedure in a patient with significant valvular disease and heart

failure or the development of infectious endocarditis represent two such life-

threatening disorders. Careful evaluation of patients’ medical histories including

the cardiac status of patients, the use of appropriate prophylactic antibiotics, and

stress reduction strategies will minimize the risk of serious cardiac sequelae.

VIII.3.Cancer

Some cancers may metastasize to the jaws and mimic endodontic pathosis,

whereas others can be primary lesions. A panoramic radiograph is useful in

providing an overall view of all dental structures. When a clinician begins an

endodontic procedure with a well-defined apical radiolucency, it might be

assumed to result from an extension of infectious agents from a nonvital pulp.

Careful examination of preoperative radiographs from different angulations is

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important since lesions of endodontic origin would not be expected to be shifted

away from the radiographic apex in the different images. If a local anesthetic is

not administered and if the patient experiences pain during access or canal

instrumentation, it is advisable to reconsider the original diagnosis because the

radiolucency may be a lesion of nonodontogenic origin.

A definitive diagnosis of a periradicular osteitis can be made only after biopsy.

When a discrepancy exists between the initial diagnosis and clinical findings,

consultation with an endodontist is advisable.

Patients undergoing chemotherapy or radiation to the head and neck may have

impaired healing responses. Treatment should be initiated only after the patient’s

physician has been consulted. Resolving the question of endodontic treatment or

extraction for preradiation patients often requires a dialogue between the dentist

and physician.

The effect of the external beam of radiation therapy on normal bone is to decrease

the number of osteocytes, osteoblasts, and endothelial cells, thus decreasing

blood flow. Pulps may become necrotic from this impaired condition. Toxic

reactions during and after radiation and chemotherapy are directly proportional to

the amount of radiation or dosage of cytotoxic drug to which the tissues are

exposed. Delayed toxicities can occur several months to years after radiation

therapy.

The outcome of endodontic treatment should be evaluated within the framework

of the toxic results of radiation and drug therapy. The cancer patient’s white

blood cell (WBC) count and platelet status should also be reviewed before

endodontic treatment. In general, routine dental procedures can be performed if

the granulocyte count is greater than 2000/mm3 and the platelet count is greater

than 50,000/mm. If urgent care is needed and the platelet count is below

50,000/mm, consultation with the patient’s oncologist is required.

VIII.4.Human Immunodeficiency Virus and Acquired Immunodeficiency

Syndrome

It is important for clinicians treating acquired immunodeficiency syndrome

(AIDS) patients to understand their patient’s level of immunosuppression, drug

therapies, and potential for opportunistic infections. Although the effect of human

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immunodeficiency virus (HIV) infection on long-term prognosis of endodontic

therapy is unknown, studies have shown that HIV patients do not have increased

risk for postoperative pain or inflammation after endodontic treatment. The

clinical team must also minimize the possibility of transmission of HIV from an

infected patient, and this is accomplished by adherence to universal precautions.

Although saliva has not been demonstrated to have transmitted the virus in a

dental situation, the potential for it to do so exists. Infected blood can transmit

HIV, and during some procedures it may become mixed with saliva. Latex gloves

and eye protection are essential for the clinician and staff. HIV can be transmitted

by needlestick or an instrument wound, but the frequency of such transmission is

low, especially with small-gauge needles.

A vital aspect of treatment planning for the patient with HIV/AIDS is

determining the current CD4 lymphocyte count and level of immunosuppression.

Generally patients having a CD4 count of more than 400 mm3 may receive all

indicated dental treatment. Patients with a CD4 count of less than 200 mm3 will

have increased susceptibility to opportunistic infections and may be effectively

medicated with prophylactic drugs. Medical consultation is advisable before

surgical procedures and before initiating complex treatment plans.

IX. Endodontic Evaluation

IX.1. When to evaluate

Suggested follow-up periods range from 6 months to 4 years. If at 6 months the

lesion is still present but smaller in size, there is an indication that it might heal

but additional recall is needed.

The larger the periapical lesion before the root canal treatment, the longer the

healing period.

IX.2. Methods of evaluation

a. Clinical examination

Failure : persistence of adverse significant signs (swelling or sinus tract) or

symptoms (spontaneous pain, dull persistent ache, or mastication sensitivity)

Success : absence of pain and swelling, disappearance of sinus tract, no evidence

of soft tissue destruction, including probing defects.

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b. Radiographic finding

SUCCESS - the elimination or nondevelopment of an area of rarefaction for a

minimum of 1 year after treatment (fig 19-1)

FAILURE - persistence or development of a radiolucent lesion that has remained

the same, has enlarged, or has developed since treatment (fig 19-2)

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QUESTIONABLE – the radiolucent lesion has neither become larger nor

significantly decreased in size. A questionable status is considered to be

nonhealing if there is no resolution after more than 1 year (fig 19-3)

IX.3. Causes of endodontic failure

a. Preoperative causes

Misdiagnosis, errors in treatment planning, poor case selection (dentists

attempting treatment beyond their skill levels), or treatment of a tooth with a poor

prognosis.

b. Operative causes

Incomplete cleaning and shaping of the canal space, not enough dense obturation

that is confined to the root canal system and then by a bad quality coronal

restoration.

c. Postoperative factors

Restoration doesn’t occur soon after obturation, presence of space between

coronal filing and obturation in cervical area.

X. Healing Mechanism

Regeneration is a process by which altered periapical tissues are completely

replaced by native tissue to their original architecture and function. Repair is a

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process by which altered tissues are not completely restored to their original

strictures. Healing of periapical lesion after root canal therapy is repair rather

than regeneration of the periapical tissues. Inflammation and healing are not two

separate entities and in fact constitute part of one process in response to tissue

injury. Inflammation dominates the early events after tissue injury, shifting

toward healing after the early responses have subsided.

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