By Barry Musikant, DMD
Post operative pain is something that keeps me humble. It generally is not severe and does not routinely occur. It can happen whether the endodontics is done in one visit or more. Endodontically treating a vital tooth is less likely to lead to a flareup even if the tooth was exquisitely sensitive to heat and cold prior to treatment. A tooth that is quite sensitive to percussion before treatment is more likely to have a flare up after instrumentation.
If the tooth is only sensitive to thermal stimuli, removing the pulp generally eliminates or greatly reduces post operative pain. Pain to percussion tells us that the inflammatory process has extended beyond the confines of the tooth into the attachment apparatus.
Knowing where we started informs us as to what is more or less likely to occur and if and when post-operative pain is present, what to do preemptively to avoid it and what additional steps to take to eliminate the pain as quickly as possible. It may sound simplistic, but the most important aspect of managing pain is to make sure the patient you just so recently worked on can get in touch with you. Every patient I treat gets my home phone number and my cell phone number if I am away. That may sound irrelevant, but when the patient has confidence that they have access to you in case of an emergency their insecurities are assuaged and the calls are less likely to come. That’s fine for the basic conditions.
From my experience teeth that are at the initial stages of pulpal degeneration display prolonged and exaggerated pain to cold. At a somewhat later stage pain may be severely initiated by heat and relieved by cold. In either case, the inflammation is confined to the pulp chamber and is generally not infiltrated with bacteria. Removing the pulp by instrumenting apically to a minimum of 30 while working the canals laterally starting with the thinnest instruments generally debrides the canal space mechanically in three dimensions while assuring an adequate space for effective irrigation. This procedure is generally sufficient to remove the inflamed tissue with minimal chances of post-op pain. Nevertheless, some patients have highly inflammatory reactions to instrumentation in general that can be exacerbated by inadvertent over-instrumentation.
Given this possibility, it is a good idea to prescribe 600-800 mg of ibuprofen, an effective non-steroidal anti-inflammatory taken before treatment and post-operatively as needed but no more often than one every 6 hours for those with mild pain. Moderate pain would include 60 mg of codeine or 10 mgs of oexycondone for severe pain. Many patients cannot take non-steroidal anti-inflammatories. The alternative medication would be 650-1000 mgs of acetaminophen for mild pain, the addition of 60 mgs for moderate pain or the addition of 10mg of oxycodone for acute pain. The patients should be informed that the use of narcotics may impair both their mental and motor skills. Interestingly, studies have shown that for those patients who can take non-steroidial anti-inflammatories, rather than taking it every 4-6 hours alone, if supported by 600-1000 mg of acetaminophen between the ibuprophen dosages the analgesic effects are enhanced.
Most post-operative pain is from inflammation of the attachment apparatus, the periodontal ligament surrounding the tooth. The pain can be from inflammation alone or from an acute infection. The pain may have been present before treatment and further exacerbated by the procedures performed or was absent initially and came about because of the treatment. If a permanent crown is not in place, it is an excellent idea to relieve the occlusion so there is little or no contact during excursive movements.
If we determine that the inflammation has an uncontrolled bacterial component, we may wish to place the patient on a course of antibiotic. Penicillin or amoxicillin 500 mg 4 times a day for 7-10 days is a typical dosage. If the patient is allergic to penicillin 150 mgs of clindamycin 4 times a day for 7days is an effective substitute. Clindamycin may also be substituted if after three days of amoxicillin or penicillin no resolution of the inflammation is reported. Antibiotics are routinely used prophylactically when patients present with certain health issues such as bone replacements, the placement of heart valves, have a history rheumatic fever etc. It should be stated that antibiotics are used in healthy patients with the understanding that the goal is to stop a spreading infection. The use of antibiotics in situations where uncontrolled infection is not present is not recommended.
If the patient is healthy, determining whether or not to give antibiotics is based on whether or not the origin of the inflammation has a bacterial component. If the tooth was non-vital to begin with and was the result of decay and obvious leakage, one can safely assume that bacteria were present in the pulp. If one sees a radiograph showing periapical bone loss, bacteria are definitely present in the periapical tissues as well. In these situations, we know bacteria are at least present and are likely a component of the pain. Giving antibiotics in these situations is appropriate again with the understanding that we are attempting to curtail the spread of post-operative infection.
If a patient is in acute pain without swelling and has a history of non-vitality without apparent bone loss, it is likely that pressure is building up behind the bone producing the extreme pain the patient is experiencing. We have three options in this situation. We could remove the obturation material reestablishing drainage while also placing the patient on antibiotics. We could limit treatment to a course of antibiotics, hoping that it will eliminate the acute infection and accompanying pain. If the pain is truly acute and removing the obturation material produces no relief, one can then purposely lay back a flap and perforate the cortical layer of bone overlying the infection releasing the backed up pressure. With the release of pressure, the blood supply will no longer be compromised in this area, the antibiotic will rapidly be more effective and the pain will subside. Tell the patient that with the relief of pain they will have a transient swelling in the soft tissues that will disappear over the next few days. The main thing is they are now out of pain.
In summary, we remain humble because we do not know beforehand how the patient will react to our procedures. There is no way we know a priori the virulence of the bacteria, how much will be pushed over the apex and the patient’s immune reaction to such insults. Hence, the reason for their ability to predictably stay in contact with you. As a dentist, we want a range of options that cover mild, moderate and severe pain for patients who can take and not take non-steroidal anti-flammatories. While not used routinely, we want the option of antibiotics when we determine that post-op pain may be coming from an infection that is out of control.