Young Bui
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 AIN
MANAGEMENT is the key to success in root canal therapy. Every patient who
walks through the door with a toothache expects the pain to go away once
he or she leaves the office. This expectation puts a lot of stress on the
dentist as he or she tries to relieve the patient of the tooth pain. Patients
should be informed prior to any treatment that they will feel some discomfort
to mild pain after the procedure for two to three days on average due to
the trauma exerted on the tooth during the procedure. In certain instances,
the pain can be moderate to severe, depending on the condition of the tooth
prior to treatment. They should also be aware that flare-ups may occur,
especially in cases with multiple appointments, retreatment cases, periradicular
pain prior to treatment, and the presence of a radiolucent lesion. By informing
patients, you will take away their worries and anxieties that something
may have gone wrong or the treatment was not successful when they experience
some pain that night.
Make sure that the patient is really anaesthetized
and comfortable before starting any treatment. It is better to over-anaesthetize
patients than to have them jump while you are instrumenting the canals.
Pain will place them in a tension state and make them feel nervous with
every sensation they may experience afterward. When giving a local injection
to the upper molars, remember to also give a palatal injection. First molars
and sometimes the second molars tend to have innervation from the palatal
nerve to the palatal root. You will realize this when drilling into the
molar and the patient starts to experience pain or when you place the reamer
into the palatal canal and the patient jumps. The palatal nerve exits at
the level of the 2nd molar about 5?6 mm from the midline.
Inferior and mental blocks tend to be a lot more
difficult to achieve than local infiltrations. It can be frustrating for
both the dentist and the patient when the entire side of the patient’s
face is completely numb but the tooth is still sensitive. There are three
secondary methods to achieve anaesthesia in these teeth. The first is interligamentary
injection by which a pressure gun is used to administer the solution into
the ligament. This quick and forceful injection can sometimes cause PDL
necrosis and a lot of postoperative pain for the patient. By using the
regular syringe and applying gentle force for a couple of minutes, you
will achieve the same result but with less damage to the PDL. You will
see the tissue blanch as the anaesthetic solution is working its way down
to the apex. The second method is intraosseous by which a small hole is
drilled into the cortical plate and the solution is administered directly
into the jaw bone. This is done by using the Stabident system. The third
is pulpal injection—and the most painful injection. You have to get access
to the pulp and then inject directly into it with back pressure. The trick
is getting access to the pulp with the least amount of pain. Look for the
area with the highest pulp horn and do a quick pecking motion with the
high speed drill with water to minimize the pain. Sometimes using the slow
speed round drill can be helpful because the heat generated from the slow
speed is not much and is more comfortable for the patient.
The worst time to give an injection is when a patient
presents with severe pain from an indurated swelling. Do not inject directly
into the area. Start with a shallow injection at the outer edge of the
swelling and then go deeper as the area is starting to get numb. Once you
are able to touch bone with little pain, then start moving inward toward
the center of the swelling. Again start with a shallow injection and continue
to go deeper as the area is getting anaesthetized. The entire injection
will take about 10?15 minutes to accomplish.
By using the apex locator, we are able to determine
the apical constriction to prevent over-instrumenting the apex. If the
apex is violated in a vital tooth, the PDL will be traumatized and the
patient will experience post-operative pain. Over-instrumenting the canal
will lead to overfilling of the canal. The extruded gutta percha point
will irritate the periapical ligament, resulting in chronic inflammation.
The patient will experience tenderness in the tooth for a long time. The
other reason not to violate the apical constriction is that debris can
be pushed beyond the opened apex resulting in flare-ups.
We can control and manage the pre-operative pain
with local anaesthesia. However, post-operative pain is more difficult
to manage. Each patient reacts differently due to different pain thresholds
and different pre-operative symptoms. One way to help prevent post-operative
pain is to reduce the occlusion so that there is no contact with the opposing
teeth. Use an articulating paper to minimize tooth removal. This is the
most important step in preventing post-operative pain. I like to prescribe
a combination of pain killer and anti-inflammatory and have them alternate
between the two every four to five hours as needed for pain. Patients who
are allergic to codeine can take a combination of 600 mg of ibuprofen and
1000 mg of acetaminophen together every six hours for pain control. Studies
show that this combination is more effective than ibuprofen alone. For
teeth with active infection or with PAR, I prescribe Augmentin 875 mg BID
and for Pen-allergic patients, Clindamycin 150 mg QID. These are the two
best antibiotics for necrotic cases or retreating failed RCT because they
kill E. faecalis bacteria which are the toughest bugs to get rid of. Dr.
Deutsch found that a cardiac dose of antibiotic right after the procedure
reduces the number of flare-ups in his patients. Remember to inform the
patient not to chew on the treated tooth for at least a week to allow it
to heal properly.
September October 2005
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Make
sure that the patient is really anaesthetized and comfortable before starting
any treatment.
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