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Endodontic pain is a complex symptom that poses unique challenges for the dentist. This book is a concise, well-structured guide to the assessment and treatment of patients who present with endodontic pain, in which step-by-step descriptions are complemented by informative images and flow charts. The advantages, disadvantages, and significance of specific diagnostic and treatment procedures are clearly described, as is a pharmacotherapeutic approach to the prevention and treatment of pain. In addition, the causes and biological basis of endodontic pain are explained and guidance is provided on further strategies for pain prevention. The crisp narrative, efficient design and visual detail are notable features of this book that will make it an ideal chairside resource for the clinician and a dependable reference for the student.



1. Diagnosis

Endodontic diagnosis represents a multidimensional challenge. It should be thought of as a process leading to an answer rather than just a question and answer. During the process the dentist collects data including the chief complaint, medical and dental histories, radiographs, and clinical tests. This is followed by synthesis of findings leading to an evidence-based diagnosis.
Early in the process the clinician must categorize patient’s symptoms as being of odontogenic or non-odontogenic origin. If it is non-odontogenic a referral is often made to another health-care practitioner with expertise in that area. If the problem is odontogenic, the dentist has another question to resolve: “Should I treat the patient or should I refer the patient to a specialist?” This chapter discusses some of the issues and guidelines associated with that question.
The patient’s medical and dental histories and description of the onset of symptoms provide information that may have a bearing on the diagnosis and treatment plan. Specific medical problems including diabetes, liver disease, and alcoholism should be discussed in terms of their impact on treatment.
Reading this chapter will enable a clinician to recognize some of the key words used by patients and how they indicate non-odontogenic or odontogenic causes of pain. Important clinical findings including stomas and the use of local anesthetic as a diagnostic tool are also reviewed. Sample patient–dentist dialogues are presented demonstrating the importance of that conversation.
Paul A. Rosenberg

2. Odontogenic and Non-odontogenic Pain

It is important for the clinician to recognize basic terminology associated with the peripheral nervous system and the biology of pain. This chapter describes the significance of allodynia, hyperalgesia, and central and peripheral sensitization. These terms are important because clinicians rely on clinical tests to evaluate the status of the pulp and periapical tissues. Hyperalgesia, allodynia, and central and peripheral sensitization are important findings during the diagnostic process.
This chapter also discusses the differential diagnosis of heterotopic (referred pain) sinusitis and headache disorders all of which can mimic endodontic pain. Herpes zoster can also pose a diagnostic challenge especially prior to the presence of intraoral or skin lesions. A classic case of herpes zoster that seemed initially to be an endodontic problem is described.
The deep, dull ache commonly caused by myofascial pain is reviewed, and the muscles most often involved are described. Differential diagnosis of myofascial pain from endodontic pain is a common problem, and this chapter reviews important diagnostic procedures that can be helpful. Headache disorders may pose another complicated diagnosis. Migraine, tension headache, and cluster headaches are reviewed since their symptoms may mislead a clinician into thinking that the patient’s pain is odontogenic in nature.
Paul A. Rosenberg

3. Radiographs and Diagnostic Tests

This chapter describes the indications and value of periapical, bitewing, panoramic, and cone beam computed tomography (CBCT) in the diagnostic process. The selection of appropriate radiographs is described in the context of ALARA (as low as reasonably achievable) in terms of radiation exposure. The importance of using more than one radiograph for diagnosis is stressed.
The biology and selection of appropriate sensibility and other clinical tests is critical to the diagnostic process. The importance of using more than one test is emphasized. Diagnostic complications are also reviewed. All sensibility tests are subject to false-positive (i.e., a positive response from a necrotic pulp) and false-negative responses (i.e., a negative response from a vital pulp).
In order to establish a diagnosis and treatment plan, the clinician must synthesize the results of radiographs, sensibility tests, and other clinical findings. No single radiograph or sensibility test is ever sufficient. Information drawn from additional radiographs or sensibility tests may be invaluable in reaching a diagnosis and treatment plan. The importance of periodontal probing is emphasized. Periodontal probing may provide important information that is not observed on radiographs or visual examination.
Paul A. Rosenberg

4. Pulpal and Periapical Diagnostic Terminology and Treatment Considerations

This chapter presents a revision of diagnostic terminology developed by the American Association of Endodontists and indicates both the previous and most current terms and definitions. The clarification is useful to the practitioner as dentists and publications often use different terms to describe pulp/periapical pathosis. This can lead to misunderstandings and confusion. Each diagnostic category is described and its clinical significance is reviewed.
In this chapter, the significance of the term “neuroplasticity” and its relationship to varied painful conditions is elaborated. The term, “atypical odontalgia,” is being revised by the Orofacial Pain Special Interest Group of the International Association for the Study of Pain. The new term, which is more specific, will be “chronic continuous dentoalveolar pain” (CCDAP). This chapter reviews the diagnostic challenge presented by atypical odontalgia (CCDAP).
A self-assessment section provides the reader with an opportunity to evaluate their skills in reaching a diagnosis and treatment plan in challenging cases.
Paul A. Rosenberg

5. Causes of Endodontic Pain and Preventive Strategies

The most common cause of pulp/periapical pathosis is caries. In this chapter host–microbial interaction and the pulp’s dynamic response to the inflammatory process is described. The process occurs within a unique low-compliance environment due to the hard unyielding walls of dentin surrounding the pulp. The result of this anatomy is an inability of the pulp to swell as it becomes progressively more inflamed. Understanding canal anatomy is an essential part of recognizing endodontic symptoms and providing emergency pain relief and subsequent therapy.
Recognizing factors that predispose a patient to pain is an important part of implementing pain-preventive strategies. While iatrogenic errors (inaccurate measurement control, over-instrumentation) often play a role in postoperative pain, there are other, less obvious, factors including genetics, gender, and anxiety that may predispose a patient to pain. The significance of these factors in relation to patient’s pain is described. Strategies to reduce patient’s anxiety are also discussed.
Postoperative pain may occur following instrumentation or obturation. Pain-preventive, evidence-based strategies, including occlusal reduction, are described.
Paul A. Rosenberg

6. Local Anesthesia

Prior to initiating endodontic treatment, achieving profound anesthesia is of primary importance. A patient’s assessment of the treatment and the dentist’s skills is largely based on achieving complete anesthesia. Many of the “horror stories” that patients relate about pain and root canal therapy are probably due to inadequate anesthesia.
This chapter will review the causes of anesthetic problems and how they are best managed. There are some cases that are more likely than others to experience anesthetic problems. It is helpful to identify those potential problem cases before treatment.
An example of an anesthetic problem is treatment of a “hot tooth” (presence of a numb lip but pain persists). Most often, this problem is associated with long-standing irreversible pulpitis in a mandibular molar. Predictable anesthetic strategies to resolve that problem are presented. The use of a variety of supplemental injections and nitrous oxide is also reviewed.
Determining the presence of profound anesthesia is essential and using a numb lip or sticking the gingiva are not dependable tests. An evidence-based approach to recognizing profound anesthesia is described.
The greatest evil is physical pain. Saint Augustine
Paul A. Rosenberg

7. Flare-Ups

The incidence of exacerbations (flare-ups) has been estimated to range from 2 to 20 %. This wide variation is due to differences in definitions of exacerbations and differences in research methodologies. This chapter describes causes of exacerbations and their treatment. Factors predisposing patients to exacerbation are reviewed. The presence of preoperative pain or mechanical allodynia (reduced mechanical pain threshold or percussion sensitivity) was found to be a positive predictor of postoperative pain in more than 15 studies.
Also noted as evidence-based predictors of postoperative pain are specific iatrogenic factors. Pulpectomy or as an alternative, pulpotomy are described as predictable means of treating endodontic emergencies. The significance and tracing of sinus tracts are also described.
The goal of an emergency visit is limited to making an accurate diagnosis and bringing the case under control symptomatically. Depending on clinical factors, incision and drainage is an important therapy in appropriate cases. Pulpectomy, pulpotomy, trephination, and occlusal reduction are reviewed as potential treatment modalities during an emergency visit.
Studies have determined that the most favorable response of periapical tissues occurred when both instrumentation and filling were short of the periapical constriction. This chapter also reviews the management of gross overfilling on the maxillary sinus and mandibular canal.
Paul A. Rosenberg

8. Therapeutics

This chapter reviews pharmacologic strategies including the use and abuse of antibiotics and analgesics. New guidelines are available to describe the indications for antibiotics. Antibiotics should be thought of as a supplement to clinical procedures in specific situations. The chapter explains why antibiotics should not be thought of as a means of “curing” an endodontic infection. The relationship of antibiotics, bacterial susceptibility, and acute abscesses is considered and evidence-based principles of antibiotic dosing are suggested.
Analgesics are presented as part of a pain-preventive (preemptive) strategy, in contrast to the historic use of analgesics only after a patient develops pain. Useful clinical tips include the advice that analgesics should be taken by the clock rather than only when a patient experiences pain.
Also reviewed is current evidence-based research supporting the use of a combination of acetaminophen and ibuprofen, to prevent and/or treat pain. That strategy is compared to the traditional use of narcotic agents to treat pain. Issues associated with addiction and drug overdose are also discussed.
Also discussed in this chapter is recent evidence concerning possible complications associated with the use of NSAIDs and acetaminophen in pregnant women and children as is evidence of sex bias in analgesic research.
Paul A. Rosenberg


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