Chapter 2. General and systemic aspects of endodontics
Use of antibiotics in endodontics13
British national formulary15
A patient’s general health may have an impact on endodontic treatment. In addition, pain is the predominant complaint associated with endodontic disease. This chapter will cover the diagnosis of orofacial pain of both odontogenic and non-odontogenic origin. The potential influence of a number of systemic conditions and disorders, as well as medication, on treatment planning and management of endodontic patients will be discussed. Sections on the use of antibiotics and analgesics in endodontic cases have also been included.
The treatment of periapical infection using modern endodontic techniques is safe and effective, provided it is appropriately applied and undertaken by competent clinicians. In line with this, a full assessment of both the medical history and the clinical situation should be undertaken prior to commencing treatment. Comprehensive and sensible treatment planning based on a careful analysis of the information gathered will help to protect the patient from harm and the dental practitioner from criticism, legal or otherwise.
The dental practitioner is largely dependent on the medical history to identify systemic disease or therapy that may affect patient management. It is, therefore, vital that this is comprehensive and regularly updated. In addition, any areas of uncertainty or concern should be discussed with the patient’s physician prior to commencing treatment. Many patients have systemic disorders, which are well-controlled by therapy and, therefore, unlikely to influence the outcome of dental treatment. However, the therapy itself may influence their management, for example patients taking prednisolone or warfarin.
The assessment will initially consist of the history and a clinical examination, which will provide a differential diagnosis. It should be remembered that the history is the single most important factor in arriving at a diagnosis. 1 However, the clinical examination and subsequent investigations will increase the clinician’s confidence in the diagnosis, even though they may contribute relatively few new facts. 2 The fear of transmission of HIV (human immunodeficiency virus) or hepatitis viruses as well as prions has highlighted the importance of applying current guidelines for cross-infection control in endodontics as in any other aspect of clinical dentistry. 3
DIFFERENTIAL DIAGNOSIS OF DENTAL PAIN
The commonest cause of pain in the orofacial region is dental disease leading to pulpal pain (see Chapter 3). As such, dental surgeons are experienced and competent in the diagnosis and management of this complaint. However, the differential diagnosis of pain in the teeth, jaws and face is far wider than is sometimes appreciated. Pain may be:
• referred from a distant origin, e.g. cardiac
• have an unusual local cause, e.g. osteomyelitis
• psychogenic in origin, e.g. atypical facial pain
• neurological, e.g. trigeminal neuralgia
• modified by apparently unrelated factors, e.g. previous cerebrovascular accident.
This broader diagnostic sieve should be remembered, particularly if the pattern of presentation is unusual, the examination findings are sparse or conflicting, or if pain persists or develops in spite of, apparently, successful treatment. The essence of good clinical practice is a methodical and disciplined approach (history, followed by examination, followed by special investigations – usually radiographic, followed by analysis and conclusion). In the case of orofacial pain this is extremely well dealt with in other texts. 4
A thorough, structured pain history will provide a diagnosis in the majority of cases and will help identify those areas in need of further investigation. This should commence with the patient being asked to describe the pain in their own words, before asking direct questions. Certain, core information (Table 2.1) should be elicited in all cases. 4
|Duration||When did your pain start?|
|Have you ever had a pain like this before?|
|Character||What type of pain is it?|
|Periodicity||When do you get the pain?|
|Does it come and go?|
|Is there any particular pattern to the pain?|
|Severity||How severe is your pain?|
|Site||Where is your pain?|
|Radiation||Does your pain spread to other areas?|
|Provoking factors||Does anything make your pain worse?|
|Relieving factors||Does anything make your pain better?|
|Associated factors||Have you noticed anything else about your pain?|
The assessment of a patient starts with their entry into the clinical setting. This will enable observation of the general demeanour as well as any locomotor problems, walking aids or possible neurological deficits. It may enable identification of a facial swelling, and particular attention should be paid to facial symmetry, notably that of the cheeks, the mandibular angle region and the nasolabial folds. Observation of the patient’s face during the history taking may reveal a subtle neurological feature requiring formal assessment of cranial nerve function. An assessment of the level of pain can be made using the facial expression, 5 although it is important to remember that facial expressions can be manipulated. Hence avoidance of, or flinching from, examination may be a more accurate indication of a trigger spot or tenderness than response to questioning during examination. The observation of mandibular movements is the essential preliminary to examination of temporomandibular joint function.
The features of a comprehensive examination of the teeth and jaws are described in Chapter 3. The soft tissues of the cheeks, palate, tongue and floor of the mouth may also yield vital, relevant information. The necessity of a detailed occlusal examination depends on the history and clinical setting. Similarly, the history will determine the necessity or desirability of formal assessment of the temporomandibular apparatus. The maxillary sinus as a cause of pain is considered below. Thermal or electrical stimulation of suspect teeth, differential local anaesthetic injections, and removal of restorations all have their place in diagnosis. In addition, radiography is essential, but all these techniques must supplement the history and clinical examination, and never replace them.
Persistent orofacial pain
The orofacial region (including the teeth) is a common site for the expression of pain or discomfort as a manifestation of underlying psychosocial disharmony. It may represent anything from a plea for help to a symptom of frank psychosis. The dental surgeon should avoid being manipulated by the patient, or their relatives, into undertaking treatment when the diagnosis is uncertain or the evidence conflicting. In such circumstances, it is better to defer active treatment until a definitive diagnosis can be obtained. In many such cases, the pain will either resolve spontaneously or provide further evidence to assist in the diagnosis, e.g. development of a hemifacial rash of herpes zoster. A review appointment should be arranged with the caveat that the patient may return sooner should the need arise. The dental practitioner also has the opportunity to refer the patient for a second opinion at any time, particularly where the diagnosis continues to remain unclear.
Certain features in the history often help in the diagnosis of idiopathic facial pain. The pain is often unremitting and may have been present for months or even years. The stated severity may be out of proportion to the observed level of distress, disturbance of life or self-therapy. The pain may not follow anatomical boundaries and may be described as throbbing, nagging, aching, miserable or cruel in nature. It does not usually disturb sleep, although there may be a coincident disturbance of sleep pattern. In addition, other chronic pain conditions such as headache, low back pain and abdominal or pelvic pain are often present. There may also be obvious secondary gain (family or social) for the sufferer. In such cases it is important to seek further information in relation to the patient’s social history and family circumstances. There is often a history of long-term or recent distressing life events, e.g. bereavement, divorce or job loss. 4
Depression is common in chronic pain patients and may be effectively detected by two simple questions: 6‘during the last month have you often been bothered by feeling down, depressed or hopeless?’ and ‘during the past month have you been bothered by having little interest or pleasure in doing things?’ Psychiatric treatment or psychotherapy is often beneficial and may be curative. Such cases are often best referred to an oral physician as direct referral to a psychiatrist may meet with difficulties.
The close proximity of the maxillary sinuses to the maxillary teeth can make the diagnosis of pain in these segments difficult. The distinction between pain of dental origin and sinusitis may be helped by the presence of obvious dental disease, or a typical acute or recurrent sinusitis with nasal discharge. Acute sinusitis rarely occurs without preceding symptoms of ‘a cold’, and tenderness to pressure of a whole quadrant of teeth is characteristic. In such cases, the use of broad-spectrum antibiotics, e.g. amoxicillin 500 mg, three times a day for 7–14 days, may be of benefit. 7 However, the clinician will need to weigh the small benefits of the antibiotic treatment against the potential for adverse effects at both the individual and general population levels. 7 Periapical infection of premolar or molar teeth may lead to purulent discharge into the sinus with associated pain. A further consideration is the risk of penetration of the sinus wall or even the sinus lining by endodontic instruments, or during apical surgery. This may result in acute sinusitis from bacterial contamination. The condition may resolve spontaneously but the prescription of a broad-spectrum antibiotic and nasal decongestant (see below) is usual practice.
Small oroantral communications usually heal spontaneously, and in the case of apical surgery, the replacement of the surgical flap is sufficient to seal the opening. The identity of microorganisms involved in sinus infection is often unclear and broad-spectrum antibiotics may be required, e.g. amoxicillin 500 mg, three times a day. It is usual to continue therapy for 5 days although a one-off 3g dose of amoxicillin is equally effective. If there is poor drainage of the sinus, e.g. a history of chronic sinusitis, nasal drops (0.5% ephedrine) should be prescribed. In addition, inhalations, such as menthol and eucalyptus, have a soothing effect and may be of benefit.
SYSTEMIC DISEASE AND ENDODONTICS
Disabled or debilitated patients cannot be expected to readily tolerate complex and lengthy treatment procedures. However, even in severe ill-health, some patients have a strong desire to retain their natural teeth, and the dentist’s duty is to try to respond. Even in terminal illness, simple treatment can be a great aid to comfort, masticatory function and morale. Good decision-making is dependent on frank and thoughtful discussion with the patient and his medical advisers. In some conditions, e.g. cardiac abnormalities, endodontic treatment should only be carried out if a high standard of treatment can be achieved, which may involve referral to a specialist.
Both the patient’s general prognosis and the prognosis for the tooth being treated must be considered; this may lead to the decision to extract the tooth rather than undertake root canal treatment. In chronic diseases, subject to cyclical remission, either spontaneously or with treatment, it is sensible to defer dental intervention until the optimum physical health is achieved. This is particularly true of haematological disorders, e.g. leukaemia, especially if the patient receives periodic transfusion or cycles of chemotherapy. Sufferers from haemorrhagic diatheses will not require factor replacement or antifibrinolytic therapy for root canal treatment alone, but may do if a local anaesthetic is to be given or endodontic surgery undertaken. In all such cases, the patient’s haematologist should be consulted to discuss any necessary preoperative or perioperative measures. Th/>