Preoperative and operative factors associated with pain after the first endodontic visit

The relationship of intracanal medicaments to postoperative pain in endodontics

AIM

To investigate the relationship of postoperative pain to three different medicaments placed in the root canal after a complete biomechanical debridement of the root canal system in patients presenting for emergency relief of pain.

METHODOLOGY

Two hundred and twenty-three teeth belonging to 221 patients presenting as emergencies to the Royal Dental Hospital of Melbourne were included in the study. Inclusion was limited to patients with a diagnosis of pulp necrosis and acute apical periodontitis. All teeth underwent conventional root canal treatment, which involved the instrumentation to the apices of each canal at the first visit. Canals were instrumented using a stepback technique and hand-files along with irrigants using Milton's (1% sodium hypochlorite) solution followed by 15% EDTAC. The canals were dried and one of the following three medicaments was inserted into the canal in random sequence: Group 1: Ledermix paste (Lederle Pharmaceuticals, Division of Cyanamid, Wolfratshausen, Germany); Group 2: calcium hydroxide paste (Calcipulpe, Septodont, France); and Group 3: no dressing. Before dismissal, the preoperative pain experienced on the previous night was recorded using a visual analogue pain scale. Patients were then instructed to record the degree of pain experienced 4 h after treatment and daily for a further 4 days.

RESULTS

The mean score pain for all three groups was between 42 and 48 prior to treatment being commenced. After 4 days, the pain score for Group 2 was 10, for Group 3 was 7 and for Group 1 was 4. Mean preoperative pain level was 44.4 (of a maximum 100) for all groups, and declined by 50% (to 22.1) after 24 h. Patients in Group 1 (Ledermix) experienced significantly less (P = 0.04) postoperative pain than those in the other two groups. There was no significant difference between Group 2 (calcium hydroxide) and Group 3 (no dressing).

CONCLUSION

Under the conditions of this study, painful teeth with acute apical periodontitis that had been dressed with Ledermix paste gave rise to less pain than that experienced by patients who had a dressing of calcium hydroxide or no dressing at all. Ledermix is an effective intracanal medicament for the control of postoperative pain associated with acute apical periodontitis, with a rapid onset of pain reduction.

Effect of drainage upon access on postoperative endodontic pain and swelling in symptomatic necrotic teeth

The purpose of this retrospective study was to determine the effect of drainage upon access on postoperative endodontic pain and swelling in symptomatic necrotic teeth. One hundred twenty-four emergency patients participated and each had a clinical diagnosis of a symptomatic necrotic tooth with an associated periapical radiolucency. The occurrence of drainage upon access was timed and recorded. After endodontic treatment, patients received ibuprofen, acetaminophen with codeine (30 mg), and a 6-day diary to record pain, percussion pain, swelling, and number and type of pain medication taken. The majority of patients with symptomatic necrotic teeth had significant postoperative pain and required analgesic medication to manage this pain. Obtaining short-term drainage upon access (average of 1.85 min) did not significantly (p > 0.05) reduce pain, percussion pain, swelling, or the number of analgesic medications taken for symptomatic necrotic teeth with periapical radiolucencies.

An unusual swelling following endodontic and prosthodontic treatment of a mandibular molar due to a foreign body reaction

AIM

The purpose of this case report is to stress the importance of taking a proper history and the appropriate evaluation of diagnostic tests in order to prevent incorrect diagnosis and treatment. Moreover, the management of postoperative problems in a healthcare system in which specialists take on specific parts of the treatment is discussed.

SUMMARY

This article describes the diagnosis and treatment of an unsuspected flare-up 1 week after root canal treatment. The swelling and pain appeared to be associated with an accidentally embedded piece of impression material. General practitioners and specialists should be aware of alternate treatment plans and treatment procedures and take these into consideration whenever there is a postoperative problem to be solved.

KEY LEARNING POINTS

Impression materials can cause a foreign body reaction when embedded in the soft tissues. History taking and evaluation of diagnostic tests are of paramount importance in order to prevent incorrect diagnosis and treatment. Both general practitioners and specialists have the responsibility to evaluate patients with a broad vision.

Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth

The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine the effect of penicillin on postoperative pain and swelling in symptomatic necrotic teeth. Forty-one emergency patients participated and each had a clinical diagnosis of a symptomatic necrotic tooth with associated periapical radiolucency. After endodontic treatment patients randomly received a 7-day oral dose (twenty-eight 500 mg capsules to be taken every 6 h) of either penicillin or a placebo control in a double-blind manner. Patients also received ibuprofen; acetaminophen with codeine (30 mg); and a 7-day diary to record pain, percussion pain, swelling, and number and type of pain medication taken. The majority of patients with symptomatic necrotic teeth had significant postoperative pain and require analgesic medication to manage this pain. The administration of penicillin postoperatively did not significantly (p > 0.05) reduce pain, percussion pain, swelling, or the number of analgesic medications taken for symptomatic necrotic teeth with periapical radiolucencies.

Postobturation pain after single- and multiple-visit endodontic therapy. A prospective study

OBJECTIVES

This prospective study was conducted to determine whether there is any significant difference in the incidence of postobturation pain after single- and multiple-visit root canal treatment (RCT).

METHODS

The frequency of postobturation pain was recorded and evaluated over an observation period of 30 days in 291 of 300 consecutive patients receiving RCT. The patients were assigned randomly and consecutively into either single- or multiple-visit groups. The canals of all teeth were prepared and filled by a single operator using the step-back and lateral condensation techniques. The data were analysed statistically to determine the relationship, if any, between the pain experienced and pulpal vitality, tooth type, pre-operative pain, and the sex and age of the patient.

RESULTS

Nine of the 300 patients were excluded from the analysis as they failed to attend for postoperative reviews. A significantly higher incidence (P < 0.01) of postobturation pain was found in the multiple-visit group (38%) than in the single-visit group (27%) within 24 h of obturation. The incidence of pain decreased thereafter, with all patients being sysmptom free at the end of the observation period. No significant correlation was found between postobturation pain and any other factor, with the exception that teeth which had nonvital pulp prior to treatment were associated with a significantly greater (P < 0.005) incidence of postobutration pain.

CONCLUSIONS

Pain was significantly higher in the multiple-visit RCT group and significantly associated with the treatment of the nonvital pulp.

A comparison of pulpectomy alone versus pulpectomy with trephination for the relief of pain

Patients who when initially seen have pain of endodontic origin have a higher incidence of posttreatment pain than those who are pain-free pretreatment. The purpose of this study was to compare two methods of treatment--pulpectomy alone or pulpectomy with trephination--for the reduction of posttreatment pain in patients presenting with acute periradicular pain of pulpal origin. Seventeen patients with pretreatment pain were studied. Eleven received a pulpectomy to the radiographically determined working length. Six patients received a pulpectomy and trephination using a #4 round bur through a vertical incision. Visual analog scales were used preoperatively to measure pain intensity and unpleasantness, and postoperatively to measure intensity, unpleasantness, and pain relief at 4, 8, 16, 24, 48, 72, and 96 h. Analysis of preoperative data showed no difference between control and experimental groups. Posttreatment, at 4 h, the trephination group reported significantly more pain intensity and unpleasantness and less pain relief than the control group. Pulpectomy alone provided significantly better postoperative pain relief at 4 h compared with pulpectomy with trephination. At no time interval did the trephination group have less pain than the group without trephination.

Factors associated with endodontic posttreatment pain

One hundred six patients with pretreatment pain presenting for endodontic treatment participated in a controlled double-blind study of dexamethasone use. Endodontic therapy was performed and, after controlling for use of nonuse of dexamethasone, patient variables and treatment factors were evaluated for their effects on endodontic posttreatment pain. Patients with no radiographic periapical lesions had significantly more pain than patients with periapical lesions at 8-, 24-, 48-, and 72-h posttreatment regardless of whether they received placebo or dexamethasone. No other patient or treatment factors correlated with posttreatment pain. Twenty-two patients in the subgroup receiving placebo reported an 81% incidence of posttreatment pain, 73% of them required posttreatment pain medications. By 72-h posttreatment, the incidence and severity of pain in the placebo group was minimal.

Prophylactic penicillin: effect on posttreatment symptoms following root canal treatment of asymptomatic periapical pathosis

It has been reported that administration of prophylactic penicillin may prevent flare-ups or other undesirable posttreatment sequelae following root canal treatment. To test this hypothesis in a prospective study, 80 patients with a diagnosis of pulp necrosis and chronic apical periodontitis were divided into three groups: group A (prophylactic penicillin, AHA recommendation), group B (placebo, same regimen), and group C (no medication). Medications and evaluations were double-blinded. Patients reported their posttreatment events including incidence of flare-ups, incidence and severity of pain/swelling, and occurrence of adverse side effects. Differences in the three groups were determined statistically using chi-square tests. The outcome showed no significant difference (p = 0.68) among the three groups. That is, administration/nonadministration of penicillin prophylactically was unrelated to posttreatment signs and symptoms following canal preparation. Incidence of flare-ups was very low (1 of 80). Occurrence of pain in the mild-moderate levels was fairly high (approximately 70% overall), but was primarily in the mild category. Overall incidence of side effects was also very low (2 of 80). Severe levels of pain/swelling and flare-up incidence were low with no difference between administration or nonadministration of antibiotics. Based on our data, using penicillin (a potentially dangerous drug) prophylactically to control posttreatment symptoms is not recommended in cases of pulp necrosis and asymptomatic periapical pathosis.

Prevention of apical periodontal ligament pain: a preliminary report of 100 vital pulp cases

A preliminary study was conducted in a private practice office to determine the incidence of postoperative pain in 100 vital pulp cases. An ophthalmic dexamethasone-neomycin solution was introduced within the root canal during the complete cleaning and shaping procedure with the purpose of premedicating and preventing apical periodontal ligament inflammation and pain. The postoperative pain outcome was compared between cases premedicated with intracanal dexamethasone-neomycin solution alone and in combination with an oral administration of Mesulide. Moderate pain was reported in 10 cases and tooth sensitivity in 13. The clinical results indicated no report of severe pain.

Incidence of interappointment emergency associated with endodontic therapy

Endodontic interappointment emergency (EIE) occurs in a low incidence following treatment by qualified operators. The purpose of this study was to assess the incidence of EIE after treatment by undergraduate students and to examine its correlation with preoperative and operative parameters. Randomly selected 334 records were retrospectively surveyed for unscheduled emergency appointments following endodontic treatment by undergraduate students. Treatment included step-back canal preparation in multiple visits with formocresol interappointment dressing. The incidence of EIE was 4.2%, and unrelated to the patients' sex and age or to tooth location. It was significantly higher in nonvital than in vital teeth (p < 0.05), with the highest occurrence in nonvital teeth unassociated with periapical radiolucency. Clinically, EIE was associated with swelling in half of the cases. It is concluded that the incidence of EIE following treatment by undergraduate students is low and related to tooth vitality.

The role of intracanal medication in root canal treatment

The role of intracanal medication as a root canal dressing is re-examined. In pulpectomy and some root canal treatments, where the root canal contains vital pulp tissue, it is doubtful whether a routine intracanal medicament is needed. In infected root canals, intracanal medication has been advocated for many purposes. An intracanal medicament is used to: (i) eliminate any remaining bacteria after canal instrumentation; (ii) reduce inflammation of periapical tissues and pulp remnants; (iii) render canal contents inert and neutralize tissue debris; (iv) act as a barrier against leakage from the temporary filling; (v) help to dry persistently wet canals. However, most of the indications for intracanal medicaments are questionable. Intracanal medicaments should only be used for root canal disinfection as part of controlled asepsis in infected root canals, and their role is secondary to cleaning and shaping of the root canal. Thorough canal debridement and adequate canal preparation are more pertinent, and their importance is emphasized. Bacteriological sampling may be necessary if a tooth does not respond to treatment, to help in the choice of intracanal medicament.