ADA Endodontics

More anesthetic may not mean better pain control

Pain control through local anesthesia is a crucial aspect of endodontic treatment. However, the most frequently used mandibular injection for achieving anesthetic success—the inferior alveolar nerve (IAN) block—is only effective from 23 percent to 57 percent of time it is used.

Doubling the cartridge volume to 3.6 milliliter of 2 percent lidocaine with epinephrine has been suggested as a potential solution by authors of previous studies. The rationale is that more of the nerve would be exposed to the anesthetic solution.

Seeking an answer to this supposition, scientists at Ohio State University conducted a retrospective study. They published their findings in the August 2013 issue of the Journal of Endodontics.

They analyzed the cases of emergency patients presenting with symptomatic irreversible pulpitis from seven anesthetic studies already conducted at the university. A total of 319 patients had received either a 1.8 mL volume of 2 percent lidocaine with 1:100,000 epinephrine (190 patients), or a 3.6 mL volume of 2 percent lidocaine with 1:100,000 epinephrine (129 patients).

Authors defined anesthetic success of the IAN block as the ability to access and instrument the tooth with a patient reporting no pain or mild pain. If a patient reported mild pain, treatment was resumed. If moderate to severe pain was experienced, additional supplemental anesthesia was given to complete the procedure comfortably.

The results showed that anesthetic success was not significantly different between the two groups. Additionally, success rates at 28 percent and 39 percent respectively, were not high enough to ensure complete pulpal anesthesia for either dosage.

"Practitioners should consider supplemental techniques, such as intraosseous or periodontal ligament injections, to achieve pulpal anesthesia when an IAN block fails to provide pulpal anesthesia for patients with irreversible pulpitis," authors advised. http://www.jendodon.com/issues

Dental abscesses drive surge in hospital stays

The number of people treated for serious dental infections in the hospital is rising, according to a study published in the September 2013 issue of the Journal of Endodontics.

After finding mere snapshots of the nature and frequency of periapical abscess hospitalizations since 2007, a group of Boston scientists conducted a retrospective analysis to learn whether associations between patient characteristics and hospitalization outcomes might exist. They also looked for longitudinal trends.

To perform the research, scientists used national patient data from the Agency for Healthcare Research and Quality. They analyzed cases that were admitted with a primary diagnosis of periapical abscess between 2000 and 2008. Patient characteristics analyzed included age, sex, race, presence of comorbid conditions and insurance status. Outcomes studied involved hospital charges, length of stay, in-hospital mortality, discharge status and complication occurrence.

During the nine-year period, the number of people admitted for dental abscesses rose significantly—from 5,757 in 2000 to 8,141 in 2008. A total of 61,439 patients were admitted for the infections. The number of in-hospital patient deaths attributed to the infections was 66.

Admissions took place on an emergency basis in 89 percent of cases, and the mean length of stay was nearly three days. Patients with sinus involvement had longer hospital stays, as did older patients. The average patient age was 37 years.

Authors noted that their study found a significant increase in hospital charges and longer lengths of stays for Medicaid-insured patients relative to privately insured patients. The finding departs from most previous research demonstrated across several medically treated populations, which showed that inpatient charges and length of stay are shortest for the uninsured followed by the Medicaid-insured, relative to the privately insured.

The study revealed a 74.3 percent increase in the number of discharges for dental abscesses billed to Medicaid from 2000 to 2008. Increases billed to Medicare were 33.1 percent and 19.3 percent to private insurers.

In discussion, authors considered that the longer hospital stays, and as a result more hospital charges, may be attributed to a greater disease severity in Medicaid-insured patients.

They surmised that the increase in patients hospitalized for dental abscesses can't be connected to an overall increase in total number of hospitalizations. Over the study period, the total number of hospitalizations in the U.S. increased by 5.3 percent. Those attributed to dental abscesses increased by 41.4 percent.

Due to its retrospective nature, the research is not a tool to determine true cause-effect relationships accurately, according to its authors.

However, they believe big-picture conclusions about the burden of hospitalizing patients with dental abscesses can be drawn based on its findings during the nine-year study period from 2000-2008, particularly:

a 41.4 percent increase in the total number;
a 32.3 percent rise in the number of emergency care admissions;
Medicare and Medicaid were the primary payers for 44 percent of all hospitalizations;
The mean hospitalization charge per visit increased 35.9 percent.

Authors said the results of the study also brought to light high-risk groups who are likely to seek a hospital setting for the treatment of periapical abscesses and groups who are associated with higher hospital charges and longer stays.

"Efforts should be made to minimize barriers of access to dental care that should result in an increase in preventative and routine dental care in a dental clinic setting, thus reducing resource utilization and the economic burden of periapical abscesses," researchers commented. http://www.jendodon.com/current

The New York Times published a report on the study and included perspectives from various dental experts on the study's findings. The increase in hospitalizations is part of a sea change in dental care, Dr. Gary R. Hartwell, president of the American Association of Endodontists, told the Times. "Now it's reached a point unless something's bothering them or they've got pain, people say, 'I'm just not going to go to the dentist.'" http://well.blogs.nytimes.com/2013/08/30/oral-infections-causing-more-hospitalizations/?_r=0

Consulting Editor: Dr. Susan Wolcott
Diplomate, American Association of Endodontists

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