Endodontic flare-ups: The Management of…(part 2 of 2)
A few weeks ago I had blogged about endodontic flare-ups.
I tried to touch upon the reasons and the processes of endodontic flare-ups. It was a part 1 of a 2 series blog. So this week I want to touch on the management of flare-ups in your office. As mentioned a few weeks ago, flare-ups happen in any dental office that performs root canal therapy. They are difficult for both the patient and dentists to handle. On the patient side, they have to deal with the pain event. On the dentist’s side, we are empathetic and caring people and thus we feel badly for our patients that endure the pain/swelling issues. We want desperately to help resolve our patient’s conditions. I hope to lend some advice so that we can help our patients.
First and foremost, we focus on anxiety reduction. Many studies have shown a relationship between anxiety, pain threshold, and post-operative pain events. Thus an appropriate discussion and explanation is critical in pain management and goes a long way to help alleviate a patient’s concerns. The more information they have the better they can understand the situation. The patient will also get the sense that we understand the situation well. This helps a patient to remain confident in the process, the treatment, and the treating dentist (you or me) if we can explain the event clearly. Return to part 1 of this blog series for explanations you can use to help relay the appropriate information to your patients.
Within this discussion of the reasons why or how flare-ups occur it is critical to let the patients know that a flare-up does not indicate endodontic failure. It does not indicate the need to extract the tooth. It does not indicate a change in the overall treatment plan. The original pre-operative prognosis of the tooth does not change with a flare-up occurrence. If the prognosis was originally classified as “good to excellent” then it will remain in that prognostic category. Patients will often expect the exact opposite, so they might feel a strong sense of relief when they understand that this pain event is not a predictor of tooth loss. I truly feel that the dialogue in a situation like this is so crucial. Reassurance, a calming perspective, and empathy have a dramatic impact on a patient’s experience. I would even suggest that the discussion is more important than any pharmacologic pain management we can offer.
Of course following the verbal communication, we must find pharmacological methods to help a patient deal with the pain and/or swelling. As you might guess, we typically turn to some combination of antibiotics and pain prescriptions.
Antibiotics:
There are many studies indicating no need for an antibiotic unless there is a clear presence of swelling. But what the studies do not generally review is the pre-operative condition of the tooth which is to say; was it a vital, non-vital, or a retreatment case. In a vital case flare-up then the chance for bacterial presence is low and I can understand an avoidance of an antibiotic. In the other two cases (non-vital or retreatment) the bacterial presence is quite likely, and thus I would recommend antibiotic use. Additionally, if the patient calls our office the day after treatment and expresses a flare-up situation, but is without swelling, it is entirely possible that a swelling might start the next day. Thus erring on the side of a precautionary approach an antibiotic makes sense. Rather than field another phone call the next day and when a swelling starts and skipping a 24 hour period when the antibiotic could have been taking effect. In our office we have some minor differences of philosophy, but for the most part we will prescribe an antibiotic.
Pain Medications:
In terms of pain medications there are many available ranging from OTC NSAID’s or Tylenol to combination (narcotic/acetaminophen) pain killers, and even corticosteroid medications (there are many others that I will not cover in this blog). We would like to provide a drug that is effective for pain relief, but at the same time use a drug that does not introduce many side effects. So understanding the pain the patient feels and understanding a patient’s level of pain tolerance can help guide us to a proper choice. I have many patients that will do very well with 600-800mg of Ibuprofen, and I have patients that will require strong medications. When we move towards a combination therapy (narcotic/acetaminophen) we typically use a pain reliever like Norco (5/325) or Tylenol #3. We rarely jump into the oxycodone narcotic medications.
Also keep in mind that taking overlapping combination therapy medications and Ibuprofen will give a greater relief of pain. In most cases it is very safe to take these medications concurrently. They work on different pain mechanisms and can act synergistically with each other. We offer this approach often in flare-up conditions. We also will use the corticosteroid Dexamethasone as an effective pain killer. In our experience we have found that this drug often trumps the effectiveness of a narcotic/acetaminophen combination.
Anesthesia:
Another great way to help manage the pain would be for the patient to return to the office to get them numb. Using a long-acting anesthetic like 0.5% Marcaine can provide hours of relief. In very severe situations this can be done twice a day or perhaps for a couple of days. Certainly it is quick, easy and best of all; the pain relief is immediate and complete. On a side note, I would also advise using this anesthetic before a flare-up even occurs. For example, we will often use this anesthetic at the immediate completion of an endodontic procedure while the patient is still numb from the original anesthetic given to perform the treatment. I would especially consider this immediate post-treatment 0.5% Marcaine in situations when a patient expresses that prior to the appointment they have not slept or ate well because of the pain. Keeping them numb for many hours after treatment will allow them to go home, get something to eat, and get some rest.
Drainage:
In cases of a flare-up that involves a fluctuant swelling we would consider incision and drainage. If there is a way to reduce the building up of pressure then an incision of the gum tissue makes plenty of sense (case dependent of course). We have often been asked if the tooth suffering from flare-up would benefit from recleaning the canal space again to establish drainage through the canal system. I, however, rarely jump back into a tooth to reinstrument. In my experience, reentering the tooth has not provided any measurable difference in flare-up relief. The only time I might consider that approach would be if during the original treatment process there was significant drainage of purulence. In that condition I might assume that the tooth still needs to drain more to reduce the pressure. If however there was no initial drainage during the original treatment, I do not reenter the tooth. I would rather seek other methodologies discussed in this blog for relief.
Occlusal Reduction:
A last consideration to manage a post-operative flare-up would be occlusal reduction. This is simply a method to reduce the stimulation of sensitized nociceptors in the ligament space. We recognize there are certain restrictive restorative factors that will affect whether or not we will reduce a tooth. For example, if a crown is in place and that crown is not expected to be replaced then we will not adjust the occlusion. However if no crown is present and the restorative plan calls for a new crown, then reduction is helpful. Even better though is to reduce the occlusion pre-operatively in these cases so as to reduce the chance of flare-up complications well before a flare-up would occur. We routinely reduce the occlusion during the access preparation of the endodontic treatment (assuming no crown, not an anterior tooth, etc).
In Conclusion:
I hope this blog helps you and your patients in the difficult situation of flare-up management. You might find yourself using several of the above methods or you might find just one method works best. Assess why the flare-up occurred and then choose the means to achieve resolution from after. Remember that not all flare-ups will resolve quickly. The strongest of flare-ups will still remain uncomfortable for a few days. And while it might not be possible to reduce the discomfort 100% completely over that course of time, it is possible to achieve at least some pain reduction so that the patient can get through the day.
Lastly and above all else, keep in mind the importance of reassurance. The flare-up will pass.
Thanks for visiting Tri City and Fallbrook Micro Endodontics of San Diego, CA.