CLINICAL EBOOK SERIES

POWERED BY

INNOVATIONS IN
ENDODONTICS
MAY 2020

2 C E C R E D I T S

FORENSIC ENDODONTICS

Determining the
Correct Course
of Endodontic
Retreatment With
No Patient History
Available
James Bahcall, DMD, MS;
Qian Xie, DDS, PhD;
Mark Baker, DDS;
Steve Weeks, DDS; and
Daniel Oh, DDS, MS

S P E C I A L R E P O R T

MANAGING OROFACIAL PAIN

Endodontic Pain
Management:
Preoperative,
Perioperative,
and Postoperative
Strategies
Brooke Blicher, DMD; and
Rebekah Lucier Pryles, DMD

SUPPORTED BY AN UNRESTRICTED GRANT FROM CARESTREAM DENTAL • Published by AEGIS Publications, LLC © 2020
 Detecting
the Problem
of Continuing Education in Dentistry

MAY 2020 | www.compendiumlive.com

A
PUBLISHER
Matthew T. Ingram
of Continuing Education in Dentistry
s clinicians, we don’t always have the benefit SPECIAL PROJECTS DIRECTOR
C. Justin Romano
of knowing a patient’s history. For example,
SPECIAL PROJECTS EDITOR
it is not uncommon for a patient to pres- Cindy Spielvogel
ent to the dental office with a problematic of Continuing Education in Dentistry
SPECIAL PROJECTS COORDINATOR
tooth that had previous endodontic treat- June Portnoy

ment, and unfortunately, the patient has no recollection BRAND COORDINATOR

Perri Lerner
of when or where the treatment occurred. What’s worse is
MANAGING EDITOR
the clinician has no past records or radiographs to refer to. Bill Noone
This is when experience and sound judgment, and a little CREATIVE
detective work, are needed to determine the correct course Claire Novo

of endodontic retreatment. EBOOK DESIGN

In this edition of the Compendium eBook Series, our CE
article discusses the importance of proper pretreatment
diagnosis and the identification of etiology in endodontic
retreatment. In cases where patients have a troublesome
previously endodontically treated tooth and cannot provide
the clinician any history regarding the original treatment,
the clinician may apply principles of what the authors call
forensic endodontics. This article reviews the clinical steps
needed to forensically determine the diagnosis and etiol-
Jennifer Barlow
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ogy of a patient’s previously endodontically treated tooth Printed in the U.S.A.

pain and/or periradicular radiographic lesion and describes

retreatment options. The article presents an intentional
replantation surgical case as an example of executing fo-
rensic endodontics.
A key component of endodontic therapy is the manage-
ment of pain. Our second article in this eBook provides
an up-to-date report on comprehensive endodontic pain
management, encompassing each stage of treatment, ie, Chairman & Founder
Daniel W. Perkins
preoperatively, perioperatively, and postoperatively. The
Vice Chairman & Co-Founder
authors offer evidence-based strategies on how to best man- Anthony A. Angelini
age patient pain at each point in the treatment sequence. Chief Executive Officer
Karen A. Auiler
Compendium offers a full complement of CE and other clin-
Corporate Associate
ical articles aimed at helping practitioners enrich their un- Jeffrey E. Gordon
derstanding of endodontics; visit our ever-expanding library Media Consultant, East
at https://www.aegisdentalnetwork.com/cced/endodontics. Scott MacDonald
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2 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com

 CONTINUING EDUCATION 1 FORENSIC ENDODONTICS

Determining the Correct Course

of Endodontic Retreatment With
No Patient History Available
James Bahcall, DMD, MS; Qian Xie, DDS, PhD; Mark Baker, DDS; Steve Weeks, DDS; and Daniel Oh, DDS, MS

ABSTRACT: Forensic endodontics is an empirical concept that has a clinical application.

By definition, forensic endodontics is the determination of the diagnosis and etiology of a
patient’s tooth pain and/or periradicular radiographic lesion on a tooth that has been previ-
ously endodontically treated. Forensic endodontics diverges from conventional endodon-
tic retreatment in that the patient has no recollection of when the tooth was treated or by
whom, and the clinician has no access to any past radiographs to assess the healing progres-
sion of the previous endodontic treatment. To determine the correct course of endodontic
therapy, the clinician needs to make a proper pretreatment diagnosis and determine the
etiology despite the absence of a treatment history. In forensic endodontic case scenarios,
the retreatment options are conventional nonsurgical endodontic retreatment, surgical
endodontics, or extraction. An intentional replantation surgical case is presented as a clini-
cal example of performing forensic endodontics.
LEARNING OBJECTIVES

• Define forensic endodontics
and how it differs from
conventional endodontic
retreatment
• Identify the clinical steps
to determine the diagnosis
and etiology of a patient’s
previously endodontically
treated tooth pain and/or
• Describe the forensic
endodontic retreatment
options that may be provided
to the patient

P
periradicular radiographic
lesion

atients frequently present to a first make a proper pretreatment diagno-

dental office or clinic with a prob-
lematic, previously endodonti-
cally treated tooth. A significant
challenge arises when the patient
has no remembrance of how long ago the
endodontic treatment was performed or who
performed it. There are no past radiographs
or records to reference, and a treatment as-
sessment must be made based only on how
the patient currently presents.
To determine the correct course of end-
odontic retreatment, the clinician needs to
DISCLOSURE: The authors had no disclosures to report.
sis and identify the etiology of the patient’s
endodontic tooth pain and/or radiographic
periradicular lesion. This type of endodon-
tic case scenario may empirically be referred
to as forensic endodontics. By definition, fo-
rensic science is the collection, preservation,
and analysis of scientific evidence during
the course of an investigation. This article
will outline the components involved in per-
forming forensic endodontics and provide a
case report describing intentional replanta-
tion surgery.

3 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com

 CONTINUING EDUCATION 1
Diagnostic Tests
After reviewing the patient’s medical and den-
tal history, which includes recording blood
pressure and pulse, the clinician must deter-
mine the diagnosis and etiology of the tooth
pain and/or radiographic lesion before per-
forming any type of endodontic retreatment.
To determine etiology, first a pretreatment
pulpal and periradicular diagnosis is obtained.
This is done by listening to the patient’s per-
ception of the problem; this “chief complaint”
is subjective. This is followed by the clinician
performing clinical sensibility testing, which
is objective, to reproduce the patient’s subjec-
tive pain symptoms.1 This testing encompass-
es the following: (1) cold, electric pulp tester
(EPT) and/or hot tests (to test pulpal status);
(2) percussion and bite tests to determine the
status of the periodontal ligament; (3) palpa-
tion testing to evaluate gingival tissue and
cortical and trabecular bone for infection or
inflammation; (4) periodontal examination
that includes periodontal probings and tooth
mobility evaluation; and (5) radiographic
examination of current periapical film, bite-
wings, and/or cone-beam computed tomog-
raphy (CBCT) scans.
Recording of Diagnostic Data
To properly determine the correct pretreat-
ment pulpal and periradicular diagnosis, the
clinician must obtain the correct test result
data after performing the aforementioned ob-
jective tests. Then, after acquiring the correct
test result data, it is important that this data
be recorded in an objective, not subjective,
manner. An example of subjective recording
of data is to use “+” or “-” symbols when docu-
menting the results of sensibility tests. Trying
to differentiate a patient’s pain level response
from the symbols “++” versus “+++” can be
difficult and is subjective. Also, clinicians typi-
cally are trained in dental school that if the
patient does not respond to pain from testing,
it should be recorded as a “-”.
4 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
FORENSIC ENDODONTICS
The recommended data recording method
is the use of medical diagnostic terminol-
ogy. The clinician, therefore, should use the
terms “abnormal” (AB) and “within normal
limits” (WNL) instead of “+” and “-”, respec-
tively, when recording palpation, percussion,
and cold sensibility testing data. In addition,
when recording cold sensibility testing, WNL,
NR (“no response”), AB/NL (“hyper-respon-
sive to cold that is non-lingering”), and AB/L
(“hyper-responsive to cold that is lingering
beyond 5 seconds”) should be used. A patient
response of AB/NL indicates a pretreatment
pulpal diagnosis correlation to reversible pul-
pitis, whereas a response of AB/L denotes a
pretreatment pulpal diagnosis correlation to
symptomatic irreversible pulpitis.
It should be noted that the time it takes for a
patient to respond to cold has no correlation
to the diagnosis and, therefore, does not need
to be recorded. What is important is whether a
patient’s response to cold is normal or hyper-
responsive and whether it lingers. Also, if a
tooth does not respond to cold and EPT tests,
the clinician should not necessarily presume
the pulp to be necrotic, because these sensibil-
ity tests stimulate only the A-delta nerve fibers
and not the C-fibers of the pulp.2,3 Therefore,
the pulp may still be vital due to the presence
of active C-fibers. With regard to recording
data for mobility and periodontal probings,
numerical documentation or the use of WNL
or AB terminology is appropriate.
Pulpal and Periradicular Diagnosis
The pulpal diagnosis in forensic endodontic
cases is “previously treated.” If the patient
reports that the root canal of the tooth is
sensitive to cold, it is highly unlikely that the
etiology is the endodontically treated tooth,
because the A-delta fibers cannot survive in a
hypoxic (low-oxygen) environment.2 In such
a scenario, the clinician should objectively
cold test the teeth adjacent to the endodonti-
cally treated teeth. Also, if a posterior tooth
 CONTINUING EDUCATION 1
is involved, the clinician should confirm with
the patient that there is no referred pain from
the maxilla to the mandibular jaw or vice versa
due to cold stimulus. Conversely, when a pa-
tient complains of sensitivity to hot stimulus,
the previously endodontically treated tooth in
question should not be eliminated from etiol-
ogy considerations. It has been reported that
C-fibers can remain vital in the extreme api-
cal portion of a root canal-treated tooth and,
therefore, respond to a heat stimulus.4
While the pulpal diagnosis is an essential
part of endodontic treatment prior to per-
forming any root canal treatment or retreat-
ment, a periradicular diagnosis is equally as
important. A study by McCarthy et al demon-
strated that patients who presented with peri-
radicular pain were better able to localize the
painful tooth (89%) in comparison to patients
who presented with tooth pain without peri-
radicular pain (30%).5 Current periradicular
diagnosis terminologies are as follows6:
Symptomatic apical periodontitis: The
tooth has a painful response to biting, palpa-
tion, and/or percussion; this may or may not
be accompanied by radiographic changes.
Asymptomatic apical periodontitis:
The tooth has no pain in response to biting,
Fig 1.
Fig 1. Periapical radiograph of tooth No. 14 does
not definitively reveal a periapical radiolucency.
Fig 2. CBCT of the same tooth No. 14 (palatal view
exposure) shown in Fig 1 definitively shows a peri-
apical lesion.
5 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
FORENSIC ENDODONTICS
percussion, or palpation. Radiograph reveals
a periradicular radiolucency.
Chronic apical abscess: Radiograph typi-
cally reveals a periradicular radiolucency.
Clinically, a sinus tract is present on the gin-
gival tissue. The draining sinus tract should
be traced with a gutta-percha cone and then
radiographed to confirm etiology and peri-
odontal diagnosis.
Acute apical abscess: This is an inflammatory
reaction to pulpal infection and necrosis char-
acterized by rapid onset, spontaneous pain, ex-
treme tenderness of the tooth to pressure, and
pus formation and swelling of associated tissues.
Radiographic signs of osseous resorption may
be present, and the patient often may experi-
ence malaise, fever, and/or lymphadenopathy.
Effectiveness of CBCT
CBCT can be used to aid in further assess-
ment of a previously endodontically treated
tooth. A study by Uraba et al demonstrated
that CBCT imaging is 20% more effective in
detecting periapical lesions that cannot be
detected on a periapical radiograph (Figure 1
and Figure 2).7 Diagnostic CBCT can provide
additional information in comparison to peri-
apical radiographs when treatment planning
Fig 2.
 CONTINUING EDUCATION 1
an endodontic retreatment case.8 The use of a
limited field of view (FOV) CBCT on a patient
that presents with a problem on an existing
endodontically treated tooth can allow the
clinician to critically evaluate the quality of
the existing canal(s) obturation, identify any
missed canals, and assess the extensiveness of
a periapical lesion.
Endodontic Retreatment Options
If a previously endodontically treated tooth
is restorable and has adequate periradicu-
lar cortical and medullary bone, endodontic
retreatment can involve either nonsurgical
retreatment and/or surgical retreatment.
The main determining factors as to which
approach a clinician should take are the
marginal integrity of the current restoration,
the radiographic (CBCT recommended) ap-
pearance of the obturation of the canal(s), the
morphology of the canal(s), and the periradic-
ular anatomy (ie, proximity of maxillary sinus
or inferior alveolar nerve). When assessing a
periradicular lesion, the clinician must bear
in mind that in forensic endodontics there
is no previous clinical or radiographic his-
tory to review. The existing lesion could be
either growing bigger, becoming smaller, or
not changing in size since the original conven-
tional endodontic treatment was performed.
Although there is an empirical inclination to
endodontically retreat by conventional end-
odontic treatment, even if the restoration is
properly intact and the previous obturation is
within normal limits, it is important to under-
stand that if the periradicular lesion is a cyst
(requiring biopsy to confirm diagnosis) it may
not heal regardless of how well the conven-
tional endodontic treatment or retreatment
is performed.9
Surgical retreatment can involve root-end re-
section/root-end filling technique, root ampu-
tation, or intentional replantation.10,11 If a tooth
has an extensive fracture (as clinically evident
by a deep periodontal probing and radiographic
6 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
FORENSIC ENDODONTICS
and/or clinical observation) or is nonrestorable,
extraction of the tooth and placement of an im-
plant, fixed bridge, or removal appliance is the
authors’ recommended treatment of choice.
In forensic endodontics the question may
arise as to whether or not any treatment should
be recommended. This may specifically be the
case when a patient presents with an asymp-
tomatic previously endodontically treated
tooth with a periapical lesion. No treatment
would entail placing the patient on 6-month
radiographic recall to monitor if the lesion is
getting larger, smaller, or staying the same size.
This may be the recommended approach if the
endodontic procedure was performed in the
past few years; however, forensic endodontics
usually involves cases in which teeth had end-
odontic treatment more than just a few years
ago. Therefore, the chance of observing any
radiographic change (demonstrating healing)
to an existing asymptomatic radiographic le-
sion at a 6-month recall is negligible.12,13
Forensic Endodontic Case Report:
Intentional Replantation
A 55-year-old man was referred by an outside
private dentist to the University of Illinois-
Chicago College of Dentistry’s department of
Graduate Endodontics for treatment of tooth
No. 18. The patient’s chief complaint was “pain
to bite on the lower left back tooth,” with the
patient pointing to tooth No. 18.
The patient’s medical and dental histories
were reviewed. The medical history was deter-
mined to be noncontributory. Blood pressure
and pulse were taken and noted to be within
normal limits. The patient reported no known
drug allergies. His dental history entailed pre-
vious restorative treatment.
The next step in the diagnostic process was
to perform objective clinical sensibility pulpal
and periradicular testing to determine the eti-
ology of the patient’s chief complaint. A peri-
apical radiograph was taken of tooth No. 18
that showed a radiolucent area present around
 CONTINUING EDUCATION 1 FORENSIC ENDODONTICS

both the mesial and distal roots (Figure 3).

Tooth No. 18 tested abnormal to percussion
and bite tests. Palpation, periodontal prob-
ings, and mobility were within normal limits.
Tooth No. 17 had been previously extracted,
and tooth No. 19 tested within normal limits
to cold, percussion, palpation, bite test, mobil-
ity, and periodontal probing sensibility tests.
The patient stated that a previous root ca- Fig 3.
nal had been performed on tooth No. 18 many
years ago, but he had no memory of the exact
date or the name of the dentist who provided
the treatment. The referring dentist had no
records or preoperative radiographs of tooth
No. 18 from before the initial endodontic treat-
ment. A limited FOV CBCT scan of the tooth
was taken, and a radiolucency was observed
on the mesial and distal roots (Figure 4). The
pretreatment pulpal diagnosis was “previously
Fig 4.
treated,” and the periradicular diagnosis was
symptomatic apical periodontitis.
The clinician determined that the treat-
ment options were conventional endodontic
retreatment or endodontic surgery, which
would involve resectioning of the mesial and
distal roots, preparation of the root ends, and
placement of a bioceramic root-end filling.
With regard to restorative evaluation, the ex-
isting crown on tooth No. 18 was deemed to be
within normal limits. Although the periapical Fig 5.
radiograph (Figure 3) showed a radiolucent
Fig 3. Preoperative periapical radiograph of tooth
line around the distal portion of the crown, the No. 18. Fig 4. CBCT sagittal view (lingual view ex-
marginal integrity was determined to be clini- posure) of tooth No. 18 revealed mesial and distal
cally acceptable. The CBCT demonstrated root periapical radiolucency. Fig 5. CBCT axial
that the inferior alveolar nerve canal was close view of tooth No. 18 revealed canal obturation
within normal limits.
in proximity to the mesial and distal roots of
tooth No. 18. Also, clinically the surgical access to the patient. He was made aware that after
around tooth No. 18 was limited for root-end a conventional endodontic retreatment there
resection endodontic surgery. The axial CBCT might be a chance that the existing lesion may
view showed that the current canal obturation not heal and further treatment intervention
was within normal limits (Figure 5). would be required. Also, in the case of per-
The treatment options for both conventional forming an intentional replantation, if tooth
endodontic retreatment and intentional surgi- No. 18 were to have a restoration or root frac-
cal replantation of tooth No. 18, including the ture upon extraction, the tooth would not
pros and cons of each option, were presented be re-implanted. The patient opted for the

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 CONTINUING EDUCATION 1 FORENSIC ENDODONTICS

intentional replantation since it could be per- confirm correlation to the patient’s subjective
formed in one treatment visit. report of profound lower left lip anesthesia. The
A left inferior alveolar nerve block was admin- patient reported no pain to either percussion or
istered using 68 mg lidocaine with 0.01 mg/ml bite test on tooth No. 18 after the administration
epinephrine. A long buccal block, along with of local anesthesia.
an intraligamental injection around tooth No. After objective confirmation of profound left
18, was given with 17 mg Septocaine with 0.01 mandibular anesthesia, tooth No. 18 was ex-
mg/ml epinephrine. Objective pulpal testing tracted and wrapped in gauze saturated with
was performed with cold stimulus to confirm saline. Under a surgical microscope, the mesial
the level of pulpal anesthesia as correlated by and distal roots were resectioned 3 mm, and
the lack of patient’s subjective response to cold the root ends of both the mesial and distal roots
stimulus on tooth No. 19. Also, percussion and were stained with methylene blue and irrigat-
bite tests were performed on tooth No. 18 to ed with saline (Figure 6). Staining was noted
around gutta-percha, but
no fracture was observed
on either root. Root-end
ultrasonic preparation
was made 3 mm in depth
on the mesial and distal
roots, and placement of a
bioceramic root-end fill-
ing was completed.10 The
entire root-end prepara-
tion and root-end fill was
conducted outside the
Fig 6. Fig 7. mouth within a 10-minute
period.11 Also, during this
time the socket of tooth
No. 18 was gently curet-
ted to remove granulo-
matous-type tissue. Not
enough tissue could be re-
moved for a biopsy. Tooth
No. 18 was then properly
reseated in the exposed
socket (Figure 7) and su-
tured into place, and a fi-
nal periapical radiograph
Fig 8. Fig 9.
was taken (Figure 8).
The patient was given
Fig 6. Extracted tooth No. 18. Under surgical microscope, root-end resec- postoperative instruc-
tion and canal preparation were performed prior to placement of root- tions and medications
end bioceramic filling. Fig 7. Tooth No. 18 immediately after replacement (amoxicillin 500 mg,
in socket prior to suturing. Fig 8. Periapical radiograph of tooth No. 18
immediately after replacement in socket. Fig 9. Periapical radiograph of ibuprofen 600 mg, and
tooth No. 18 at 2-month recall appointment. chlorhexidine mouth

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 CONTINUING EDUCATION 1
rinse). He returned to the clinic 5 days post-
treatment for suture removal and evaluation.
No radiograph was taken at the 5-day post-
operative recall visit. The patient presented
with tooth No. 18 intact and slightly mobile
and reporting slight discomfort of the surgi-
cal area. At a 2-month recall tooth No. 18 was
found to be asymptomatic and fully reinte-
grated into the socket (Figure 9). Mobility
and periodontal probings were within nor-
mal limits.
Summary
Although forensic endodontics is an em-
pirical concept, it has a clinical application.
Forensic endodontics is defined as the deter-
mination of the proper pretreatment pulpal
and periradicular diagnosis and etiology of a
patient’s tooth pain and/or periradicular le-
sion on a tooth that was previously endodon-
tically treated. In forensic endodontics the
patient has no recollection of when the tooth
in question was treated or by whom. Also, no
past records or radiographs are available to
the clinician to evaluate the prior endodontic
treatment, and therefore a treatment assess-
ment must be made based only on the cur-
rent presentation of the patient. Endodontic
retreatment options in forensic endodontics
are conventional nonsurgical retreatment,
surgical endodontics, or extraction. An in-
tentional replantation surgical case was pre-
sented as a clinical example of performing
forensic endodontics.
ABOUT THE AUTHORS
James Bahcall, DMD, MS
Clinical Professor, Department of Endodontics, University of
Illinois-Chicago, College of Dentistry, Chicago, Illinois
Qian Xie, DDS, PhD
Assistant Professor, Department of Endodontics, University
of Illinois-Chicago, College of Dentistry, Chicago, Illinois
Mark Baker, DDS
Clinical Associate Professor, Department of Endodontics,
University of Illinois-Chicago, College of Dentistry, Chicago,
Illinois
9 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
FORENSIC ENDODONTICS
Steve Weeks, DDS
Clinical Assistant Professor, Department of Endodontics,
University of Illinois-Chicago, College of Dentistry, Chicago,
Illinois
Daniel Oh, DDS, MS
Second-year endodontic resident, University of Illinois-
Chicago, College of Dentistry, Chicago, Illinois
Queries to the author regarding this course may be submitted
to authorqueries@aegiscomm.com.
REFERENCES
1. Bahcall J, Johnson B. Clinical guide to treat-
ing endodontic emergencies. Inside Dentistry.
2016;12(4):46-48.
2. Jain N, Gupta A, Meena N. An insight into neu-
rophysiology of pulpal pain: facts and hypotheses.
Korean J Pain. 2013;26(4):347-355.
3. Närhi M, Virtanen A, Kuhta J, Huopaniemi T. Elec-
trical stimulation of teeth with a pulp tester in the
cat. Scand J Dent Res. 1979;87(1):32-38.
4. Keir DM, Walker WA 3rd, Schindler WG, Dazey
SE. Thermally induced pulpalgia in endodontically
treated teeth. J Endod. 1991;17(1):38-40.
5. McCarthy PJ, McClanahan S, Hodges J, Bowles
WR. Frequency of localization of the painful tooth
by patients presenting for an endodontic emer-
gency. J Endod. 2010;36(5):801-805.
6. AAE Consensus Conference Recommended Di-
agnostic Terminology. J Endod. 2009;35(12):1634.
7. Uraba S, Ebihara A. Komatsu K, et al. Ability of
cone-beam computed tomography to detect peri-
apical lesions that were not detected by periapical
radiography: a retrospective assessment accord-
ing to tooth group. J Endod. 2016;42(8):1186-1190.
8. Patel S, Brown J, Pimentel T, et al. Cone beam
computed tomography in endodontics - a review
of the literature. Int Endod J. 2019;52(8):1138-1152.
9. Torres-Langares D, Segura-Egea JJ, Rodriguez-
Caballero A, et al. Treatment of a large maxillary
cyst with marsupialization, decompression, sur-
gical endodontic therapy and enucleation. J Can
Dent Assoc. 2011;77:b87.
10. Wang ZH, Zhang MN, Wang J, et al. Outcomes
of endodontic microsurgery using a microscope
and mineral trioxide aggregate: a prospective co-
hort study. J Endod. 2017;43(5):694-698.
11. Becker BD. Intentional replantation techniques:
a critical review. J Endod. 2018;44(1):14-21.
12. Strange KA, Tawil PZ, Phillips C, et al. Long-term
outcomes of endodontic treatment performed
with Resilon/Epiphany. J Endod. 2019;45
(5):507-512.
13. Sjögren U, Hägglund B, Sundquist G, Wing K.
Factors affecting the long-term results of end-
odontic treatment. J Endod. 1990;16(10):498-504.
 CONTINUING EDUCATION 1 QUIZ
Determining the Correct Course of Endodontic
Retreatment With No Patient History Available
James Bahcall, DMD, MS; Qian Xie, DDS, PhD; Mark Baker, DDS;
Steve Weeks, DDS; and Daniel Oh, DDS, MS
TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/INNENDO1
1. In forensic endodontics, the clinician must
make a treatment assessment based only on:
A. how the patient currently presents.
B. past radiographs.
C. r ecords from before the initial endodontic
treatment.
D. existing CBCT scans.
2. The clinician must determine the diagnosis
and etiology of the tooth pain and/or
radiographic lesion:
A. before reviewing the patient’s medical and
dental history.
B. b
 efore performing any type of endodontic
retreatment.
C. after performing endodontic retreatment.
D. after executing a forensic science
investigation.
3. Used in determining etiology, clinical
sensibility testing is considered to be:
A. outdated.
B. subjective.
C. objective.
D. unnecessary.
4. Clinical sensibility testing includes which of
the following?
A. cold test, electric pulp test, and/or hot test
B. percussion testing
C. periodontal examination
D. All of the above
5. When documenting the results of sensibility
tests, the recommended data recording
method is the use of:
A. “+” and “-” symbols.
B. subjective certification.
C. medical diagnostic terminology.
D. All of the above
Course is valid from 4/1/2020 to 4/30/2023. Participants
must attain a score of 70% on each quiz to receive credit. Par-
ticipants receiving a failing grade on any exam will be notified
and permitted to take one re-examination. Participants will
receive an annual report documenting their accumulated
credits, and are urged to contact their own state registry
boards for special CE requirements.
10 COMPENDIUM EBOOK SERIES 2020 | | Volume
April2020
May Volume41x Number 9
2 Hours CE Credit
ENTER PROMO CODE: IEN1
6. The pulpal diagnosis in forensic endodontic
cases is:
 A. normal pulp.
B. previously treated.
C. symptomatic irreversible pulpitis.
D. pulp necrosis.
7. McCarthy et al demonstrated that in
comparison to patients who presented
without periradicular pain, patients with
periradicular pain:
A. were less able to localize the painful
tooth.
B. w
 ere better able to localize the painful
tooth.
C. were unable to localize the painful tooth at all.
D. were able to localize the painful tooth in
every situation.
8. When the tooth has no pain in response
to biting, percussion, or palpation,
and radiograph reveals a periradicular
radiolucency, the diagnosis is:
A. symptomatic apical periodontitis.
B. a symptomatic apical periodontitis.
C. c hronic apical abscess.
D. acute apical abscess.
9. Surgical retreatment can involve root-end
resection/root-end filling, root amputation,
or, as was done in this case:
A. intentional replantation.
B. dental implant placement.
C. gingival enlargement.
D. pulpal innervation.
10. In the case presented, the patient had had a
previous root canal performed on tooth No. 18:
A. 2 years ago by a dentist in the same town.
B. w ithin the past 3 years by a dentist in a
different state.
C. 5 years ago by a dentist whom the patient
knew.
D. many years ago by a dentist whom the
patient could not remember.
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 SPECIAL REPORT
Endodontic Pain Management:
Preoperative, Perioperative,
and Postoperative Strategies
O
Brooke Blicher, DMD; and Rebekah Lucier Pryles, DMD
rofacial pain is often the impe-
tus for patients to seek dental
care, and endodontic disease
accounts for a significant pro-
portion of this pain. That said,
fear of pain during dental procedures is a
major deterrent for many prospective dental
patients. Thankfully, pain management strat-
egies have significantly improved over time.
Managing endodontic pain at all stages of di-
agnosis and treatment—preoperative, periop-
erative, and postoperative—may be achieved
with a variety of evidence-based and reliable
pain management approaches.
The foundation of pain management is the de-
termination of pain source and development of
a definitive diagnosis. Delivery of definitive care,
either by endodontic therapy or extraction, is
the best way to provide complete relief of pain
of endodontic origin.1 Beyond this, pain manage-
ment should be considered prior to the provision
of definitive care, perioperatively while care is
being delivered, and postoperatively until signs
and symptoms of inflammation and infection re-
solve. This article highlights evidence-based pain
management strategies and briefly discusses the
future direction of orofacial pain management.
Preoperative Pain Management
When definitive care cannot be delivered imme-
diately, oral analgesics offer convenient and ef-
fective means to relieve even severe dental pain.
Over-the-counter oral analgesics include both
nonsteroidal anti-inflammatory drugs (NSAIDs)
and acetaminophen. Ibuprofen is the most stud-
ied drug in the NSAID class due to its convenient
11 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
MANAGING OROFACIAL PAIN
dosing, high safety profile, and ready availability
without a prescription. It functions by blocking
the cyclooxygenase (COX) 1 and 2 enzymes to
prevent production of prostaglandins involved in
both pain transmission and inflammation.1 The
maximum recommended dosage of ibuprofen
is 3200 mg/day, with common dosages ranging
from 400 mg to 800 mg every 4 to 8 hours.2 Major
side-effects include gastrointestinal upset and
are dose dependent; thus, the lowest effective
dosage should be utilized.3
Furthermore, care must be exercised when
prescribing NSAIDs to patients with cardiac
disease. A 30% increased risk of myocardial in-
farction is associated with exposure to ibuprofen
in the 30 days prior to the event.4 These risks exist
even in patients who have taken ibuprofen for
relatively short durations, particularly with dos-
ages larger than 1200 mg/day.5 However, when
compared to selective COX-2 inhibitors like ce-
lecoxib, NSAIDs, including ibuprofen, showed a
lesser risk of cardiovascular disease6; thus, they
remain the drug of choice, especially in patients
with other cardiovascular risk factors.
Acetaminophen functions to block prosta-
glandin synthesis peripherally and interacts
with cannabinoid and serotonergic receptors
centrally.7 The manufacturer’s maximum rec-
ommended dosage of acetaminophen is 3000
mg/day. Given the risk of hepatoxicity associated
with acetaminophen, the lowest effective dosage
is recommended.8
Prescription oral analgesics include cortico-
steroids and opioid class drugs. Although they
have shown efficacy in treating severe dental
pain, corticosteroids like prednisalone and
 SPECIAL REPORT
Beyond this, pain management should be considered prior
to the provision of definitive care, perioperatively while
care is being delivered, and postoperatively until signs
and symptoms of inflammation and infection resolve.
dexamethasone have a higher side-effect profile
than NSAIDs and generally have cross-reactiv-
ity when patients are sensitive to these drugs.9
Therefore, their use is not routinely recom-
mended. Opioid class drugs include complexes
of codeine, hydrocodone, oxycodone, and trama-
dol. These drugs act centrally on mu and kappa
receptors to alter pain perception.1 Though not
as effective as the pain relievers discussed above,
these drugs produce feelings of euphoria and re-
duce anxiety; thus, patients in severe pain can
rest and oftentimes escape notice of their severe
pain. Nonetheless, risks of misuse and addiction,
and resultant rules and regulations limiting their
use, suggest avoidance of these medications
whenever possible.
According to the Oxford league table, NSAIDs
possess greater efficacy than opioids in the treat-
ment of severe dental pain.10 Combination ther-
apy utilizing NSAIDs and acetaminophen has
shown greater efficacy in the treatment of severe
dental pain than either drug alone.11 Mild to mod-
erate pain is often relieved by 400 mg ibuprofen
combined with 325 mg acetaminophen dosed
every 6 hours, whereas more severe pain may re-
quire 600 mg or 800 mg ibuprofen and up to 1000
mg acetaminophen every 8 hours. Simultaneous
administration of ibuprofen and acetaminophen
has shown improved efficacy over alternating
courses12 and should be encouraged.
Local anesthetics, like oral pain medications,
can provide hours of pain relief for patients
with endodontic pathology, particularly when
longer-acting drugs like bupivacaine are utilized.
Moreover, the administration of local anesthetics
12 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
MANAGING OROFACIAL PAIN
may further act to support a correct diagnosis
when used as part of selective anesthesia.13
While oral pain medications and local anes-
thetics possess significant utility in managing
preoperative pain, antibiotics are not effective
pain relievers.14 Providers should limit their pre-
scription to situations with uncontrolled, sys-
temic spread of infection, or where medical com-
promise warrants their use prophylactically.15
Perioperative Pain Management
Perioperative pain management in endodontics
centers around the achievement of profound lo-
cal anesthesia. Unfortunately, patients suffering
from severe pain of endodontic origin, particu-
larly symptomatic irreversible pulpitis, may ex-
perience difficulties in achieving adequate pulpal
anesthesia due to issues with techniques, altered
pH, or inflammation of the surrounding tissues
resulting in pharmacologic failure.1 Since nei-
ther patients nor providers wish to experience
breakthrough pain during treatment, and poor
past experiences can lead patients to avoid dental
care in the future, it is imperative that clinicians
provide pain-free care.
The literature supports specific techniques for
achieving pulpal anesthesia in teeth with symp-
tomatic irreversible pulpitis. Successful pulpal
anesthesia of maxillary teeth can be obtained
by infiltrations on the buccal surfaces alone. No
gains in anesthesia success are obtained through
the addition of a posterior superior alveolar
nerve block or palatal anesthesia.16 For man-
dibular teeth, achievement of successful pulpal
anesthesia can be more complex. Mandibular
 SPECIAL REPORT
anterior teeth may be successfully anesthe-
tized by infiltrations alone, whereas premolars
are most successfully anesthetized by the com-
bination of mental and inferior alveolar nerve
blocks (IANBs).17,18 Mandibular molars require
block anesthesia, usually with the addition of an
adjunctive anesthetic technique. Success rates
of the IANB alone are quite low and alterna-
tive block techniques, including the Gow-Gates
and Vazirani-Akinosi, show no greater effective-
ness.18,19 Buccal infiltration with articaine exhib-
its the greatest efficacy as an adjunct to the IANB
block, although other techniques, including
intraligamentary and intraosseous anesthesia,
are also effective.20 When all else fails, or when
breakthrough sensitivity occurs mid-procedure,
intrapulpal anesthesia may be used.21
In general, the type of anesthetic solution se-
lected does not appear to impact anesthetic suc-
cess. Both articaine and lidocaine provide equally
efficacious infiltration anesthesia.22 When con-
sidering block anesthesia, no differences have
been found in the efficacy of commonly available
mepivacaine and lidocaine solutions.23 Articaine
and other 4% solutions are discouraged for block
anesthesia due to increased risks of paresthesia.24
Adequate dosages of any of these drugs must
be used to achieve profound pulpal anesthe-
sia, as a dose-response relationship exists.
Administration of 3.6 mL of anesthetic solution
via IANB shows significantly fewer pulpal an-
esthesia failures in mandibular molars than 1.8
mL of solution.25
Local anesthesia alone may be insufficient for
perioperative pain control in some patients. In
such cases, additional pharmacologic agents
may be used to increase its efficacy. Nitrous
oxide itself acts as an analgesic and can im-
prove the efficacy of local anesthetic solutions.
Benzodiazepines, however, do not potentiate the
effects of local anesthetics, and should only be
expected to reduce procedure-related patient
anxiety. Preoperative use of oral analgesics, in-
cluding dexamethasone, NSAIDs, and tramadol,
may improve effectiveness of IANB injections in
13 COMPENDIUM EBOOK SERIES May 2020 | Volume 41 Number 9 www.compendiumlive.com
MANAGING OROFACIAL PAIN
patients with symptomatic irreversible pulpitis,
although controversy exists.26-28
Postoperative Pain Management
While definitive treatment of endodontic pa-
thology is the optimal means to alleviate severe
pain, some degree of postoperative discomfort
is normal. Most patients report mild discomfort
after endodontic treatment with minimal impact
on daily living. Only 6% of patients report more
acute pain following treatment, consistent with
a postoperative flare-up. Patients report resolu-
tion of most pain symptoms within 2 to 3 days,
and 90% report complete pain relief by 1 week
following endodontic treatment.29 Since post-
operative pain is common and to be expected,
clinicians need to warn patients to anticipate its
presence and arm them with strategies to mini-
mize its impact. In addition to verbal communi-
cation, written instructions can effectively help
manage patient expectations and clearly define
normal and abnormal conditions that may war-
rant contacting an available emergency provider.
Like in the management of preoperative pain,
oral medications, including combination therapy
with ibuprofen and acetaminophen, are most ap-
propriate for the management of postoperative
pain. Opioid class drugs are less effective and
should be avoided if possible. Long-acting an-
esthetics like bupivacaine are useful adjuncts
to ensure pain relief through the acute postop-
erative period when pain can be most severe.
Bupivacaine possesses properties to provide
extended analgesia even beyond its half-life, ac-
cording to studies in the medical literature.30
Future Considerations
Areas of development to further improve pro-
found pulpal anesthesia include a promising
nasal spray that can anesthetize the maxillary
anterior sextant.18 Also, given the significance
of opioid misuse, research will no doubt focus
on the development of non-addictive alternative
substances. Newer formulations of existing drugs
may increase their bioavailability and potency.
 SPECIAL REPORT
ABOUT THE AUTHORS
Brooke Blicher, DMD
Clinical Instructor, Department of Restorative Dentistry and
Biomaterials Sciences, Harvard School of Dental Medicine,
Boston, Massachussetts; Assistant Clinical Professor,
Department of Endodontics, Tufts University School
of Dental Medicine, Boston, Massachusetts; Diplomate,
American Board of Endodontics; Private Practice limited to
Endodontics, White River Junction, Vermont
Rebekah Lucier Pryles, DMD
Assistant Clinical Professor, Department of Endodontics,
Tufts University School of Dental Medicine, Boston,
Massachusetts; Lecturer, Department of Restorative
Dentistry and Biomaterials Sciences, Harvard School
of Dental Medicine, Boston, Massachusetts; Diplomate,
American Board of Endodontics; Private Practice limited to
Endodontics, White River Junction, Vermont
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