Factors associated with continuing pain in endodontics

A survey of 100 patients referred to a specialist endodontic practice was undertaken to determine the frequency of various factors associated with continuing pain after endodontic treatment had been commenced by the patient's general dental practitioner. Information was obtained by questioning the patient, examining the tooth, reviewing information supplied by the referring dentist and by observation during subsequent treatment. There were 23 different factors associated with continuing pain — all patients had more than one factor; most (78 per cent) had four, five or six factors; the highest was 9 factors (2 per cent). The most commonly occurring factors were: lack of use of rubber dam (87 per cent), unsatisfactory temporary restorations (80 per cent), and inappropriate use of intracanal medicaments (71 per cent). The other factors were related to diagnostic or treatment errors that could have been avoided in most cases. This survey suggests that dentists need to pay more attention to basic treatment recommendations in order to predictably relieve pain when carrying out emergency endodontics.     

Severe odontogenic infections

Background : Severe odontogenic infections are serious potentially lethal conditions. Following the death of a patient in the authors' institution this study was initiated to determine the risk factors, management and outcome of a consecutive series of patients.
Methods : All patients admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with odontogenic infections in calendar year 2003 were investigated. Detailed information relative to their pre-presentation history, surgical and anaesthetic management and outcome was obtained and analysed.
Results : Forty-eight patients, 32M, 16F, average age 34.5, range 19 to 88 years were treated. All presented with pain and swelling, with 21 (44 per cent) having trismus. Forty-four (92 per cent) were as a result of dental neglect and four (8 per cent) were regular dental patients having endodontic treatment which failed. Of those known to have been treated prior to presentation, most had been on antibiotics. Most patients had aggressive surgical treatment with extraction, surgical drainage, high dose intravenous antibiotics and rehydration. The hospital stay was 3.3 (range 1–16) days. Patients requiring prolonged intubation and high dependency or intensive care (40 per cent) had longer hospitalization. No patient died and all fully recovered.
Conclusion : Severe odontogenic infections are a serious risk to the patient's health and life. Management is primarily surgical with skilled anaesthetic airway management. Antibiotics are required in high intravenous doses as an adjunct and not as a primary treatment.     

Diagnosis and treatment of dental emergencies in two Finnish cities

According to the present clinical survey of dental emergencies treated by organised emergency services in two of the larger Finnish cities, the main causes (64 per cent) of the problems leading to these visits were caries and its consequences. In about 80 per cent of the 839 cases treated, the acute treatment was based on clinical examination only. Temporary fillings were provided for 19 per cent, permanent fillings for 8 per cent, endodontic treatment for 22 per cent and extractions for 14 per cent of the patients. Extractions were most often provided for patients who normally visited a dentist irregularly and these had a low mean number of teeth. Patients with pain lasting longer than a week were likely to receive endodontic treatment, whereas permanent fillings were provided for regular dental visitors who had their own dentists. About 90 per cent of the patients were considered to need other dental treatment in addition to the treatment of the acute condition.     

Incompletely fractured teeth associated with diffuse longstanding orofacial pain: diagnosis and treatment outcome

AIM: To evaluate the diagnostic value of different clinical findings, and analyse the symptoms experienced from teeth with incomplete dentinal fractures in patients with diffuse orofacial pain. Secondly, to present the outcome of different treatment modalities in these patients. METHODOLOGY: Thirty-two patients, referred to the teaching clinic at the Faculty of Dentistry, University of Bergen, with poorly localized orofacial pain, were finally diagnosed with 46 incompletely fractured teeth. The distribution and pattern of pain was thoroughly recorded for each patient. The final diagnosis, incompletely fractured tooth, was obtained after removal of fillings and direct inspection of possible fracture lines. RESULTS: Many of the patients had suffered diffuse orofacial pain for more than 1 year, and had earlier consulted dental and medical expertise. Direct inspection of fracture lines, combined with staining solution and transillumination proved to be the best diagnostic tools. The longer the duration of pain before the diagnosis of an incompletely fractured tooth was established, the more diffuse was the distribution of pain. Endodontic or restorative treatment relieved the symptoms in 90% of the patients, whilst persisting symptoms in 10% were considered part of an orofacial pain complex of obscure aetiology. CONCLUSION: This study shows that the diagnosis of the incompletely fractured teeth in patients with longstanding diffuse orofacial pain symptoms are time consuming and represent a diagnostic problem. With appropriate endodontic and/or restorative treatment, symptoms were relieved in the majority of cases.     

Public dental service utilization among adults in South Australia

Background:  Longitudinal patterns of public dental service use may reflect access issues to public dental care services. Therefore, patterns of dental service use among South Australian adult public dental patients over a 3½-year period were examined.
Methods:  Public dental patients (n = 898) initially receiving a course of emergency dental care (EDC) or general dental care (GDC) at baseline were followed for up to 3½ years. Patient clinical records were accessed electronically to obtain information on dental visits and treatment received at those visits.
Results:  Some 70.7 per cent of EDC and 51.3 per cent of GDC patients returned for dental treatment post-baseline. EDC patients returned within a significantly shorter time period post-baseline, received significantly more courses of care and were visiting more frequently than GDC patients. A greater proportion of EDC patients received oral surgery, restorative, endodontic and prosthodontic services, but fewer received periodontic services. EDC patients received significantly more oral surgery and fewer preventive services per follow-up year, on average, than GDC patients. Large proportions of EDC (52.4 per cent) and GDC (63.8 per cent) patients who returned sought emergency care post-baseline.
Conclusions:  Patients appeared to be cycling through emergency dental care because of lack of access to general care services, highlighting access problems to public dental care.     

Dilemma in treatment of patients suffering from orofacial dysaesthesia

A retrospective study of 64 patients with orofacial dysaesthesia is presented. Special emphasis is placed on the patients' symptoms and on the manipulative treatments they received before they were referred for psychiatric consultation. The patients had suffered from chronic orofacial pain or feelings of discomfort for periods ranging from 6 months up to 25 years. The patients had visited several specialists and had received numerous manipulative or medical treatments, the most common of which were repeated medication (drug treatment), TMJ dysfunction treatment, endodontic or exodontic treatment, and surgical explorations. However, the success of all these clinical efforts was very limited because of the apparent psychosomatic origin of the complaints. This study clearly shows that psychiatric consultations are still too seldom made in patients with chronic orofacial dysaesthesia, that many patients have a mental disorder, and that most chronic psychosomatic pain disorders are treated as acute specific pain.     

Diagnosis and management of non-dental orofacial pain

Careful history-taking improves diagnosis of non-dental orofacial pain, a not uncommon group of conditions. Accurate diagnosis of conditions such as chronic idiopathic facial pain, temporomandibular disorders, burning mouth syndrome and trigeminal neuralgia is essential if inappropriate dental treatment is to be avoided. There are few investigations to help in the diagnostic process and many of these patients have other forms of chronic pain. All the conditions are best treated using a holistic approach. Drugs, such as tricyclic antidepressants and anticonvulsants, are often effective and surgery can be highly successfully in trigeminal neuralgia. Patient education is paramount. CLINICAL RELEVANCE: Although the majority of pain seen in general dental practice is dental in origin, chronic non-dental orofacial pain must be recognized as its management is entirely different.     

Assessing restored teeth with pulp and periapical diseases for the presence of cracks, caries and marginal breakdown

BACKGROUND: To determine whether clinical examinations and periapical radiographs provide sufficient information to assess the cause of pulp and periapical diseases, the status of teeth when restored and their further treatment needs. Other aims were to determine whether restorations should be removed prior to commencing endodontic treatment, and whether the type and longevity of restorations were related to the presence of disease. METHODS: Information was collected regarding 245 restored teeth from 220 consecutive patients referred for endodontic treatment. Teeth were examined before and after the restorations were removed and the findings were compared. RESULTS: Pre-operative examination revealed 47 (19.2 per cent) teeth had caries, 57 (23.3 per cent) had cracks and 96 (39.2 per cent) had marginal breakdown. After restoration removal, the figures were 211 (86.1 per cent), 147 (60 per cent), and 244 (99.6 per cent) respectively. Almost all teeth (93 per cent) had more than one of these factors and periapical radiographs were unreliable indicators of their presence. There was only a 56.1 per cent chance (with 95 per cent Confidence Interval) of finding caries, cracks or marginal breakdown prior to restoration removal. Composite resins were more often associated with early onset and rapid progression of pulp diseases. CONCLUSIONS: All restorations should be removed prior to endodontic treatment in order to remove the common factors that may have caused the pulp and periapical disease, and to assess the tooth's prognosis and future treatment needs.     

Cardiac murmurs: echocardiography in the assessment of patients requiring antibiotic prophylaxis for dental treatment

Background : Traditionally patients who indicate that they have a heart murmur or who indicate that they have had rheumatic fever are given antibiotic prophylaxis for dental treatment. This is commonly done without further assessment of the patient's actual endocarditis risk. Echocardiography is a non-invasive method of assessing cardiac valve function and haemodynamics.
Methods : Consecutive patients who were referred to a private practice oral and maxillofacial surgeon for dentoalveolar surgery and indicated that they had a cardiac problem and usually had antibiotic prophylaxis, were evaluated. Those with a clear indication for prophylaxis, for example had prosthetic heart valves or previous infective endocarditis, received antibiotic prophylaxis. Where there was uncertainty, they were referred for an echocardiogram, and if abnormal, a formal cardiology review.
Results : Three hundred and seventy patients out of approximately 20 000 (1.85 per cent) indicated that they had a cardiac murmur and usually received antibiotic prophylaxis for dental treatment between 1 February 1997 and 1 February 2005. Two hundred and sixty-two (71 per cent) were female and 108 (29 per cent) were male; age range 0.7 to 98 years, average 37.6 years. Two hundred and seventy (72 per cent) had normal hearts with no indication for antibiotic prophylaxis. Of the 100 (28 per cent) patients with abnormal findings, they were on average older; 49.5 years, range 0.7 to 87 years. Of these, 50 (14 per cent) met current indications for antibiotic prophylaxis.
Conclusion : Patients who present for dental treatment indicating that they require antibiotic prophylaxis for cardiac condition need to be fully evaluated. In this study only 50 of 370 patients (14 per cent) required antibiotic prophylaxis. The remaining 320 (86 per cent) would have no benefit but a risk of adverse reaction to the antibiotic.     

Variables affecting endodontic recall

Aim  To determine the recall rate in an endodontic practice and to evaluate specified variables as to their effect on the rate of patients returning for recall.
Methodology  The records of 7105 patients treated by one endodontist between 1975 and 1998 were reviewed. Recorded variables included chart number, patient gender and age, treated tooth number, pulp status, presence of spontaneous pain at initial visit, history of trauma to treated tooth, previous root canal treatment in the treated tooth, and presence of endodontic recall.
Results  The recall rate was 49% for the 5641 patients who completed endodontic treatment. Odds ratio analysis showed that females returned for recall at a rate that was significantly higher than males (52% vs. 44%). Odds ratio and chi square analysis revealed that a diagnosis of pulp necrosis or previous root filling resulted in a higher than expected recall rate while a diagnosis of irreversible pulpitis resulted in a lower than expected recall rate ( p  < 0.001). Patients aged 6–40 years of age returned at a lower rate than expected and those aged 41–80 returned at a higher rate than expected ( p  < 0.001). There was no significant difference in recall rate for patients reporting spontaneous pain or history of trauma with the treated tooth. The type of treated tooth had no effect on patient recall rate.
Conclusions  Forty-nine per cent of patients returned for recall after a minimum of 6 months with patient age, patient gender and pulp status affecting the rate of recall significantly.     

Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing

AIMS: To (i) determine the prevalence of persistent dento-alveolar pain following nonsurgical and/or surgical endodontic treatment conducted in a teaching dental hospital and (ii) identify the risk factors associated with persistent pain after apparently successful root canal treatment. STUDY DESIGN: A total of 175 patients/teeth were reviewed 12-59 months following treatment. The patients were examined clinically and radiographically and a detailed pain history obtained. Multiple logistic regression analysis was used to investigate the association between potential risk factors and persistent pain after successful endodontic treatment. RESULTS: The prevalence of persistent pain after successful root canal treatment was 12% (21/175). Treatment success was determined by the absence of clinical and radiographic signs of dental disease. The factors that were significantly (P < 0.05) associated with persistent pain following endodontic treatment were: 'duration of preoperative pain' [odds ratio (OR) = 8.6], 'preoperative pain from the tooth' (OR = 7.8), 'preoperative tenderness to percussion' (OR = 7.8), 'previous chronic pain problems' (OR = 4.5), 'gender' (OR = 4.5) and 'history of painful treatment in the orofacial region' (OR = 3.8). 'Type of treatment received (surgical or nonsurgical treatment)' showed borderline significance at the 10% level. CONCLUSIONS: The presence and duration of preoperative pain from the tooth site, lasting at least 3 months, a positive history of previous chronic pain experience or painful treatment in the orofacial region, and female gender were important risk factors associated with persistent pain after successful endodontic treatment.     

The diagnosis and surgical management of major salivary gland pathology

BACKGROUND: Major salivary gland pathology is an uncommon but important finding which may initially present to general dental and medical practitioners. The consequences of misdiagnosis are important, as acute obstruction and neoplasia are the main pathological lesions diagnosed. The purpose of this study was to analyze a consecutive series of major gland pathologies treated surgically to determine diagnostic and treatment problems. METHODS: A retrospective analysis of all cases of the major salivary glands treated on an inpatient surgical basis over a five-year period by the Oral and Maxillofacial Surgery Unit of the Royal Adelaide Hospital was performed. Particular emphasis was placed on the referring diagnosis as compared to the final diagnosis. RESULTS: Fifty-four patients had surgical management of 62 major salivary glands over the five-year period. By gland, 18 (33.3 per cent) were parotid, 35 (51.1 per cent) submandibular and nine (16.6 per cent) were sublingual. Fifty-one (82 per cent) of all lesions were inflammatory and 11 (18 per cent) neoplastic. The most common presentations were swelling (72 per cent) and pain (33 per cent). Most patients were referred by general dentists (37 per cent), followed by general medical practitioners (32 per cent) and specialists (28 per cent). The referring diagnosis was correct for only 45 per cent of the dentists but 76 per cent for the general medical practitioners and 87 per cent for the specialists. Only two of the 11 gland neoplasms were correctly identified as neoplasms, both by specialists. The morbidity of the surgical treatment was low. CONCLUSION: The general dental practitioner is often the first health professional with the opportunity to assess salivary gland pathology, and therefore needs to be aware of the presenting signs and symptoms of major salivary gland lesions.     

Post-traumatic stress disorder among patients with orofacial pain

AIMS: To examine the presence and impact of post-traumatic stress disorder (PTSD) in a sample of patients seeking treatment for orofacial pain. METHODS: One hundred forty-one consecutive patients with an array of orofacial pain conditions were screened using a structured clinical interview for PTSD and the PTSD Symptom Checklist--Civilian Version (PCL), a brief PTSD self-report inventory. Additionally, participants received a clinical examination and self-report questionnaires to assess pain, coping styles, and presence of post-traumatic symptoms. RESULTS: Thirty-three (23%) patients received a full lifetime or current PTSD diagnosis, with an additional 11 patients receiving a partial PTSD diagnosis. Only 5 of these 44 patients had ever been previously diagnosed with PTSD. PTSD symptoms were associated with higher pain scores (P < .05) and affective distress (P < .01). Furthermore, discriminant function analyses suggested that the PCL accurately classified 89% of these cases (sensitivity = .85, specificity = .90, positive predictive power = 74%, negative predictive power = 95%). CONCLUSION: These results suggest that PTSD is prevalent in the orofacial pain setting and that PTSD symptomatology is associated with increased pain and affective distress that may complicate clinical presentation. Furthermore, PTSD can be accurately and efficiently assessed using a brief, self-report inventory.     

Effect of prophylactic amoxicillin on endodontic flare-up in asymptomatic, necrotic teeth

The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine the effect of prophylactic amoxicillin on the occurrence of endodontic flare-up in asymptomatic, necrotic teeth. Seventy patients participated and had a clinical diagnosis of an asymptomatic, necrotic tooth with associated periapical radiolucency. One hour before endodontic treatment, patients randomly received either 3 g of amoxicillin or 3 g of a placebo control in a double-blind manner. After endodontic treatment, each patient received: ibuprofen; acetaminophen with codeine (30 mg); and a 5 1/2-day diary to record pain, swelling, percussion pain, and number and type of pain medication taken. The results demonstrated 10% of the 70 patients had a flare-up characterized by moderate-to-severe postoperative pain or swelling that began approximately 30 h after endodontic treatment and persisted for an average of 74 h. Of the seven patients who had flare-ups, 4 were in the amoxicillin group and 3 were not. Prophylactic amoxicillin did not significantly (p = 0.80) influence the endodontic flare-up. We concluded that a prophylactic dose of amoxicillin before endodontic treatment of asymptomatic, necrotic teeth had no effect on the endodontic flare-up.     

Contribution of Endodontic Pathology to Persistent Orofacial Pain: A Case Report

Identifying the etiology and correct diagnoses for long-standing orofacial pain can be very challenging, especially in patients who have both odontogenic and nonodontogenic pain. This case report describes the successful management of a complex case of chronic orofacial pain in a patient with nonodontogenic chronic pain conditions and a maxillary molar tooth with persistent periapical pathology after endodontic treatment. The debilitating orofacial pain began after initial nonsurgical root canal treatment of the maxillary molar 3 years before presenting to our clinic. The initial clinical and radiographic assessment by our multidisciplinary team found that there were potentially both peripheral endodontic pathology and central pain mechanisms contributing to the long-standing pain. The diagnosis was shared with the patient's neurologist, who prescribed gabapentin, a centrally acting analgesic, and partial pain reduction was achieved. The odontogenic component of the orofacial pain was then addressed, by treating the persistent periapical infection and buccal bone fenestration of the roots of the maxillary molar. Treatments included both nonsurgical retreatment and surgical endodontic therapy (including root resection, root-end preparation, and retrofilling), and each significantly improved the patient's ongoing orofacial pain. After the successful endodontic treatments, the patient reported minimal pain and normal oral function. The case report highlights the importance of systematically treating endodontic pathology in a patient with long-standing orofacial pain, with both odontogenic and nonodontogenic components.     

Referred pain of muscular origin resembling endodontic involvement. Case report

Referred pain is common in the orofacial region and can cause considerable difficulties in diagnosis. Referred pain is defined as pain that is referred to a part of the body other than the site of origin, and as a result, severe pain may arise without an associated causative lesion. A muscular trigger point that resembled a tooth with endodontic involvement is discussed.     

Radiographic evaluation of cases referred for surgical endodontics

AIM: The aim of this study is to test the hypothesis that more patients with failed root-canal treatment or other endodontic problems are referred for periradicular surgery rather than nonsurgical re-treatment. METHODOLOGY: Three sets of 100 periapical radiographs representing typical cases referred for surgical treatment were collected in three departments of oral and maxillo-facial surgery situated in different parts of the Netherlands. Of these, a total of 278 radiographs were evaluated to determine whether endodontic surgery was indicated or whether the primary endodontic treatment or endodontic re-treatment was a realistic option. An oral and maxillo-facial surgeon, an endodontist and a general dental practitioner viewed the radiograph independently under standard conditions. RESULTS: Overall, orthograde root-canal (re-)treatment was considered possible in 63% of the cases. The results differed between the three examiners with the oral surgeon reporting that 41% of cases were amenable to conventional treatment, for the general dental practitioner and the endodontists the figures were 67 and 80%, respectively. CONCLUSIONS: Based on these observations, it is concluded that most of the teeth referred for surgical treatment to an oral surgeon could be treated by orthograde nonsurgical root-canal treatment.     

Chronic orofacial pain: a clinical challenge

Most orofacial pain originates in the oral cavity and the surrounding structures. However, advances in the understanding of pain neurophysiology have shown that convergent afferent nociceptive transmissions from non-trigeminal, extraoral sources can enter the trigeminal system. This may confuse the diagnosis by presenting as (or contributing to) dental, sinus, temporomandibular and other head and neck pains. Incorrect diagnoses may lead to inappropriate and/or invasive procedures, creating further problems. Professor Richard Kroening (former Director of the UCLA Pain Management Center) repeatedly emphasised the maxim that "without correct diagnosis, there can be no prognosis". My own areas of special interest have included acute pain management (anaesthesia and conscious sedation) and chronic orofacial pain. I have seen many dental patients who have been referred to multidisciplinary pain management clinics, often after years of failed treatment attempts. More recent experience as a member of a hospital team evaluating long term ACC patients with many types of persistent pain problems again confirms the premise that accurate diagnosis is critical if management is to be successful.     

Gabapentin therapy in patients with orofacial neuropathic pain: Report of 12 cases

Objective

There are several types of orofacial neuropathic pain and some of these types are often refractory to treatment. Gabapentin is an oral antiepileptic agent with a proven analgesic effect in various traumatic neuropathic pain syndromes. We retrospectively examined the analgesic effect of gabapentin on non-dental and non-traumatic orofacial neuropathic pain.

Subjects and methods

This study included 12 patients. All patients showed an excessive response to noxious (hyperalgesia) and/or innocuous (allodynia) stimuli in the affected region. Gabapentin therapy was initiated with a dosage of 200–600 mg/day. Pain intensity was assessed using a modified numerical rating scale (m-NRS) (0, no pain; 10, pain equal to that experienced on the day gabapentin therapy was initiated). In addition, the side effects were also recorded.

Results

All the patients had received medications for their pain prior to referral, but the drugs failed to provide adequate relief from their neuropathic pain. The m-NRS scores for all patients started decreasing within 7 days after internal use was initiated. The average time taken for the m-NRS score to decrease to half was 3.3 (1.7) days. Side effects were observed in 2 patients.

Conclusion

We concluded that gabapentin therapy is efficacious for the treatment of orofacial neuropathic pain in selected patients.     

The incidence of preoperative and postoperative pain in endodontic therapy

Summary. In this study the incidence of preoperative and postoperative pain of endodontic origin of 1204 teeth, treated by 10 dentists, was recorded. All endodontic treatments were completed in one visit except those where lack of time, continuing exudation or treatment to induce apexification did not permit it. The results show that postoperative pain occurred in approximately 29 per cent (7 per cent severe, 22 per cent moderate) of all visits and that there existed a strong positive correlation between the presence of preoperative pain and the incidence of postoperative pain. Based on this observation it is concluded that in studying postoperative pain after endodontic treatment knowledge of the preoperative status is a prerequisite. The results also showed that severe postoperative pain was usually reduced to a tolerable level within 3 days. Out of all treatments that were classified as emergency treatment the therapy chosen relieved the patient's pain in 35 per cent, while in 39 per cent it was reduced to moderate pain and in 14 per cent severe pain persisted. However, only 12 per cent of all these emergency treatments required further treatment.