Pain Management After A Root Canal Therapy

Someone once told me that "knowledge sharing is the learning, learning is the knowledge sharing". The moment that we decided to be health care providers, we are forever all embarked on a lifetime of learning. Knowledge sharing is ingrained in our human DNA. We progressively strive to connect and collaborate with others so that our learning curve never becomes flat. I would like to share with you my experiences and knowledge in pain management after a root canal therapy.

According to Harrington, flareup is described as the occurrence of pain, swelling or the combination of these during the course of root canal therapy, which results in unscheduled visits by patients. Common clinical conditions associated with flareups are:

1) Apical periodontitis associated with treatment (over instrumentation & medication, forcing debris beyond the apical constriction)
2) Incomplete removal of pulpal tissue during the initial appointment
3) Necrotic with asymptomatic apical periodontitis cases (occurs in teeth with necrotic pulp and apical lesions that are asymptomatic)
4) Recurrent periapical abscess (the abscess may recur more than once, due to micro organism of high virulence or poor host resistance)

Prevention of flareups:
*Proper diagnosis: Identify the correct tooth causing pain. Ascertain whether tooth is vital or non vital. Identify if tooth is associated with periapical lesion.
*Determine correct working length: Radiographs & Apex locaters
*Complete extirpation of vital pulp.
*Copious Irrigation: Preferably with combination of irrigants such as sodium hypochlorite and chlorohexedine.
*Avoid filing too close to the radiographic apex.
*Reduce tooth from occlusion especially if apex is severely violated by overinstrumentation.
*Placement of intracanal medicaments.
*Prescription of mild analgesics and antibiotics whenever condition warrants it.

Pharmacological Approach Pain Management

Acute Apical Abscess/Cellulits: With or W/O Incision & Drainage
Combination Therapy
*500 mg Metronidazole, 8 tablets: 1 per oral every 12 hours for four days
*500 mg Augmentin, 8 tablets: 1 per oral every 12 hours for four days

Necrotic w/swelling cases:
*875 mg of Augmentin, 14-20 tablets: 1 per oral every 12 hours for 1 week prior to procedure and up to three days after procedure if necessary.

All other conventional endodontic cases:
*500 mg of Naprosyn (Naproxen), 8 tablets: 1 per oral every 12 hours for four days. After the four days of anti-inflammatory, I instruct the patient to continue with 220mg of Aleve once every 12 hours for the next 2-3 days (6 tablets).

Office emergency visit with severe pain cases:
*0.75 mg of dexamethasone, 20 tablets
2 stat, then 1 per oral every 6 hours for the first two days, then 1 per oral every 8 hours for the 3rd & 4th day, then 1 per oral every 12 hours for the 5th & 6th day