Successful management of pain is a critical aspect of dentistry. This becomes a great challenge when patients present to clinic with a painful endodontic emergency. Management of acute symptoms of irreversible pulpitis can be difficult to manage especially in the posterior lower quadrants. As IANB success in patients with irreversible pulpitis can be as low as 30%.
The infamous “hot tooth” is caused by inflammation of the pulp, and is hypersensitive to stimuli due to inflammatory mediators reducing the activation threshold of of nociceptor neurons in the pulp to a point that even minor provocation will lead to these neurons firing.
Inflammation also activates capsaicin sensitive vanilloid receptors which act as sensors for the changes in pH and heat in the pulp. A reduction in temperature completely blocks these receptors from becoming active hence the observation of cooling reducing pain in severe pulpitis.
Oral premedication with an analgesic can help increase the efficacy of IANB! Comparing the effectiveness of placebo to various oral premedication analgesics, this meta-analysis found that dexamethasone and NSAIDs increase the success rate of IANB compared to other medications.
Dexamethasone is a glucocorticoid and is said to reduce acute inflammation through suppression of vasodilation, preventing migration and phagocytosis of polymorphonuclear leucocytes, and inhibiting production of prostaglandins and leukotrienes by blocking the COX and lipoxygenase pathways.
NSAIDs rank second in increasing overall efficacy of IANB in patients with irreversible pulpitis. As a refresher, NSAIDs reversibly inhibit the cyclooxygenase pathway, affecting prostaglandin and thromboxane inflammatory mediator production, ultimately leading to reduced nociceptor activation.
Oral premedication in conjunction with good nerve block technique and supplementary doses of anesthesia can help ease the pain of the patient and the stress of the provider. Education of reception staff and great communication in these scenarios goes a long way in helping to triage patients with irreversible pulpitis prior to presentation to clinic.
Today’s Morning Huddle was brought to you by S. J. Pulikkotil et al.