Pulpotomy vs. Pulpectomy
- When is a pulpotomy versus a pulpectomy indicated?
- How can we help our patients when they are in pain and time is limited?
- How much time should the front office schedule for an emergency?
We all feel bad for our patients when they have a terrible toothache and these are the questions for which we often need answers, quickly. It all goes back to the pulpal and periradicular diagnosis. (Refer to Blog Post #1 published on our website in January 2018)
A patient with Symptomatic Irreversible Pulpitis (SIP) only (pain to hot/cold, but no pain to chewing) will greatly benefit from a pulpotomy.
A patient with both SIP and Symptomatic Apical Periodontitis (SAP) will require a total pulpectomy (and a bite adjustment if possible) to feel better.
Lastly, a patient with a Necrotic pulp and SAP will require a total pulpectomy up to size 25 or 20 to the apical terminus.
What’s the key point to takeaway on this?
Pain to temperature is amenable to a quick pulpotomy, but if your patient displays a toothache with pain to biting, you’ll need to complete most if not all instrumentation to get them feeling good.
Additional measures that can be taken to alleviate endo related tooth pain are:
Use one or two carpules .05 Marcaine 1/200K epi field block (IANB or Gow Gates) to provide long lasting relief. Many studies have shown that it helps “break the pain cycle” to help the patient “turn the corner” on their way to feeling better. Interestingly enough, although mandibular blocks with Marcaine are successful, maxillary field blocks such as a PSA don’t last longer or provide additional relief.
Another advantage to the use of Marcaine when the patient has a bad toothache is that it allows them to get some sleep.
I recommend administration of the Marcaine field block only after the patient is already numb. Due to the chemical composition, Marcaine stings more than Lidocaine during the injection which is not what a patient wants when they already have a bad toothache.
Marcaine results in more profound and longer acting local anesthesia, but the onset of action is around ten minutes, so give it plenty of time to work!
Make sure to discuss getting the “ceiling effect” from NSAIDS before the patient starts taking narcotic analgesics such as Vicodin. All narcotics have side effects of dizziness, nausea and constipation. Although they are occasionally necessary for short time periods, a quick diagnosis and proper endodontic treatment will greatly reduce the need for narcotic pain medicine.
Once you have made your diagnosis and anesthetized the patient, give them 800mg Ibuprofen and 1 gm Tylenol if there are no medical contraindications. The sooner we start reducing the presence of inflammatory mediators around the tooth, the better J.