A prospective randomized double-blind trial on efficacy of dexamethasone for endodontic interappointment pain in teeth with asymptomatic inflamed pulps

Systemic Corticosteroid Uses in Endodontics-Part 1: Managing Postoperative Pain

INTRODUCTION

This study aimed to systematically search and review all available literature regarding systemic (oral or locally injected) corticosteroids in endodontics to assess their effect on postoperative pain.

METHODS

A search was conducted using PubMed, Cochrane Library, Embase, Scopus, Dentistry & Oral Science, and ProQuest. Randomized controlled trials enrolling participants undergoing endodontic treatment and assessing the presence of pain and pain scores at 6, 12, and 24 hours postoperatively were included. We synthesize the effect measures using risk ratios (RRs), standardized mean differences (SMDs), and their corresponding 95% confidence intervals (CIs). Meta-analysis was performed using the random-effects inverse variance method. The level of significance was set at P < .05. The certainty of the evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

A total of 2303 participants from 29 trials were included. Patients who received corticosteroids were significantly less likely to report pain at 6 hours (RR = 2.5; 95% CI, 1.74-3.61; P < .00001), 12 hours (RR = 2.10; 95% CI, 1.53-2.90; P < .00001), and 24 hours (RR = 1.77; 95% CI, 1.38-2.28; P < .00001) postoperatively. Furthermore, they reported lower pain intensity at 6 hours (SMD = - 0.82; 95% CI, -1.17 to -0.48; P < .00001), 12 hours (SMD = - 0.63; 95% CI, -0.75 to -0.51; P < .00001), and 24 hours (SMD = - 0.68; 95% CI, -0.90 to -0.46; P < .00001) postoperatively.

CONCLUSIONS

Moderate certainty evidence indicates that the use of systemic corticosteroids likely results in a moderate to large reduction in postoperative endodontic pain.

Incidence and Intensity of Pain Following Endodontic Treatment by Different Instrumentation Techniques in Teeth With Periapical Lesion

AIM AND OBJECTIVES

 This study was carried out to compare the effectiveness of hand and rotary instrumentation techniques on postoperative pain in asymptomatic necrotic premolars with periapical lesions and instrumented by a modified step-back technique using a K file, crown down by continuous rotary motion technique using ProTaper Universal (Dentsply Mailefer, Ballaigues, Switzerland), and with the reciprocation technique using WaveOne (Dentsply Sirona, Charlotte, NC, USA).

MATERIALS AND METHODS

 For this study, 66 premolars with single roots and canals were chosen. The procedure was completed in a single visit. Following access opening, the working length was initially determined using an apex locator and then confirmed after inserting K file #10 by radiograph. The canal was cleaned and shaped using a grouping system. After the master apical preparation, the canal was dried by paper point and obturated with gutta-percha and AH plus sealer, an epoxide-amine resin pulp canal sealer. In order to confirm the obturation, a radiograph was taken. After that, a permanent restoration material was used to seal the access cavity. Following that, patients to whom the visual analog scale (VAS) had already been explained were contacted by phone at six, 12, 24, and 48 hours.

RESULTS

 In this study, compared to a stainless steel instrumentation technique, WaveOne instrumentation caused more noticeable pain. The results of the current study showed that, on average, postoperative pain scores decreased over the course of the 12 to 48-hour period, reaching a minimum or a maximum at 48 hours (p<0.01).

CONCLUSION

 Postoperative pain was produced by all instrumentation methods used in the study. In comparison to ProTaper and WaveOne, instrumentation using the modified step-back technique with K files caused less pain, especially over the course of a 24-hour period.

Effect of premedication on postoperative pain after root canal therapy in patients with irreversible pulpitis: a systematic review and meta-analysis

This systematic review aimed to assess the effect of premedication on postoperative pain after root canal treatment in vital teeth. Five electronic databases were searched for randomized clinical trials, and two independent reviewers selected eligible studies, extracted data, and assessed the quality of studies using the Cochrane Risk of Bias tool. Meta-analysis was conducted using the random-effects model, and the pooled effect estimate of the standardized mean difference (SMD) between premedication and placebo was calculated. Subgroup analysis was conducted based on the class and route of the drug. Studies with a high risk of bias were excluded from the sensitivity analysis. Ten trials satisfied the inclusion criteria, of which eight were included in the meta-analysis. Premedication was more effective in reducing postoperative pain than placebo at 6 hours (SMD = −1.00; 95% confidence interval [CI] = −1.33 to −0.66), 12 hours (SMD = −0.80; 95% CI = −1.05 to −0.56), and 24 hours (SMD = −0.72; 95% CI = −1.02 to −0.43). The results of the sensitivity analysis confirmed the findings of the primary analysis. Based on these results, it can be concluded that premedication is effective in reducing postoperative pain in teeth with irreversible pulpitis. However, additional quality studies are required for further validation.

Pharmacological Management of Acute Endodontic Pain

Pain associated with infections of the tooth pulp and periapical tissues is intense and often the most common reason for patients seeking emergency dental care. Effective management of acute dental pain requires a deep understanding of pain mechanisms, which enables accurate diagnosis and definitive treatment. While drugs are only used as an adjunct to definitive dental treatment, a thorough understanding of their mechanism of action and effectiveness enables clinicians to effectively control intra-operative and post-operative pain and prevent persistent pain. This review describes how pain is detected, processed, and perceived. It also provides information on evidence-based strategies on the use of different classes of drugs to effectively manage endodontic pain.

The Safety and Efficacy of Pre- and Post-Medication for Postoperative Endo- dontic Pain: A Systematic Review and Network Meta-analysis

Background:

Postoperative Endodontic Pain is a major concern for dentists and their patients, with pain having been reported to occur in 25%–40% of patients treated. Therefore, the aim of this systematic review and Network Meta-analysis (NMA) was to identify the safety and efficacy of pre- and post-medication for reducing postoperative endodontic pain.

Methods:

A literature search was performed in the SCOPUS, MEDLINE, and ScienceDirect, and Cochrane Central databases until December 2019 with no language restriction. Randomized controlled trials evaluating the efficacy of pre- or post-medications compared with other agents, placebo, or no treatment in adult patients who underwent endodontic surgery for postoperative pain were included. The mean difference of postoperative pain was measured using the Standardized Mean Difference (SMD) with its 95% confidence interval (95% CI).

Results:

This Systematic Review included 62 Articles. Of them, 50 studies were included in the NMA. Among all medications, corticosteroids were ranked as the best treatment for the reduction of postoperative pain at 6 and 12 hours with a significant reduction in postoperative pain scores [SMD= -1.18, 95% CI (-1.51: -0.85)] and [SMD= -1.39, 95% CI (-1.77: -1.02)], respectively. Cyclooxygenase-2 (COX-2) inhibitors were ranked as the best treatment for the reduction of postoperative pain at 8 and 24 hours with a significant reduction in postoperative pain scores [SMD= -2.86, 95% CI (-6.05: -1.66)] and [SMD= -1.27, 95% CI (-2.10: -0.43)], respectively. Non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduced the postoperative pain scores in all durations. For postoperative pain at 6 hours, Indomethacin, Novafen, Naproxen, Prednisolone, Ketorolac, Betamethasone, Dexamethasone, Deflazacort, Rofecoxib, Piroxicam, and Ibuprofen significantly reduced the pain score when compared with a placebo. All of these drugs demonstrated a significant reduction at 12 hours except Ketorolac.

Conclusion:

The current evidence suggests that pre- and post-medication can reduce postoperative pain after nonsurgical root canal treatment. Corticosteroids and COX-2 inhibitors showed significant control of the pain up to 12 hours after administration. However, NSAIDs demonstrated a high efficacy from administration and until two days after treatment. Indomethacin, Novafen, prednisolone, and Naproxen were ranked first in most analyzed durations.

Effect of Pulpotomy Procedures With Mineral Trioxide Aggregate and Dexamethasone on Post-endodontic Pain in Patients with Irreversible Pulpitis: A Randomized Clinical Trial

Objective:

Endodontic post-treatment pain continues to be one of the main problems encountered by dental professionals. Therefore, pain control during and after endodontic treatment is one of the most important issues in endodontics. The purpose of this clinical trial was to compare postoperative pain relief achieved with dexamethasone (DEX) and mineral trioxide aggregate (MTA) used as pulp coverage after pulpotomy in human molars with irreversible pulpitis.

Methods:

This prospective double-blind study was conducted on 54 patients complaining of dental pain due to irreversible pulpitis. The standard pulpotomy procedure was performed by the same dentist in all patients. At the time of the cotton pellet placement, patients were randomly divided into three groups: those in whom a sterile dry cotton (DC) pellet was used, patients treated with a cotton pellet soaked in MTA, and those who were treated with a cotton pellet soaked in DEX. After completion of the treatment, patients received rescue medication every 6 hours for the first day. Postoperative pain was assessed at 6-hour intervals for 24 hours, and then every day until day 7 using a visual analog scale.

Results:

In general, patients treated with MTA suffered the lowest levels of pain at all time intervals. Post-pulpotomy pain was significantly reduced at 18 and 24 hours and from days 2 to 7 post-treatment in the MTA group. DEX lowered the pain level more than the DC pellet. However, the differences observed in the mean pain scores of the DEX and DC pellet groups at all-time intervals were not statistically significant.

Conclusion:

Pulpotomy procedures can reduce pain related irreversible pulpitis. Pulpotomy with MTA-soaked cotton pellet significantly reduces pain intensity in patients with irreversible pulpitis.

Effect of pretreatment medication on postendodontic pain: A double-blind, placebo-controlled study

BACKGROUND

Posttreatment endodontic pain has been reported in 25%-40% of all endodontic patients. Effective management of endodontic pain represents a continuing challenge.

AIM

To evaluate and compare the efficacy of preoperative single dose of nonsteroidal anti-inflammatory drug, piroxicam (20 mg), with two types of corticosteroid drugs - dexamethasone (4 mg) or deflazacort (30 mg) - for the prevention and control of postendodontic pain.

MATERIALS AND METHODS

A total of 132 volunteers selected for nonsurgical root canal therapy were randomly divided into the following four groups (n = 30 each) according to preoperative medication given: Group 1, piroxicam (20 mg); Group 2, dexamethasone (4 mg); Group 3, deflazacort (30 mg); and Group 4, placebo. The preoperative medications were administrated 1 h before the start of standard endodontic treatment. Patients were instructed to complete a pain diary using Visual Analog Scale preoperatively and at 6-, 12-, 24-, 48-, and 72-h intervals after root canal instrumentation.

STATISTICAL ANALYSIS

The correlation between preoperative endodontic pain to postoperative pain and pair-wise comparison of four groups was evaluated by Kruskal-Wallis analysis of variance test followed by Mann-Whitney U-test.

RESULTS

Compared to the placebo group, piroxicam, dexamethasone, and deflazacort resulted in a statistically significant reduction in postendodontic pain at 6, 12, and 24 h (P < 0.05).

CONCLUSION

Preoperative single oral dose of piroxicam or dexamethasone or deflazacort is equally effective in controlling postendodontic pain.

Efficacy of corticosteroids for postoperative endodontic pain: A systematic review and meta-analysis

This systematic review aimed to analyze the efficacy of corticosteroid premedication compared to placebo or no treatment to reduce postoperative pain in endodontic patients. Randomized controlled trials (RCTs) assessing corticosteroids via oral, intramuscular, subperiosteal, intraligamentary or intracanal route compared to passive or active placebo, or no treatment were included. Four databases were searched: PubMed, Web of Science, Cochrane Library and Embase up to 2/21/2018. Risk of bias was assessed with Cochrane Risk of bias tool. Fourteen RCTs with 1,462 generally healthy adults in need of endodontic treatment were included. 50% of the studies were at unclear risk and 50% at high risk of bias. Meta-analysis showed Visual Analog Scale (VAS) pain at 4-6 hours after Inferior Alveolar Nerve Block (IANB) was significantly lower by 21 points (0-100 scale) in the corticosteroid group compared to the control group (95% CI -35 to -7; P = 0.003), however this difference was not statistically significant after 24 hours (P = 0.116). The route of administration was oral and intraligament injection. Patients who received corticosteroids prior to IANB were 70.7% more likely to have none or mild pain 4-8 hours after treatment (P = 0.001) and 13.5% more likely 24 hours after IANB (P = 0.013) than patients in the control group. In conclusion, corticosteroid administration (oral or intraligamental) may clinically reduce the level of postoperative pain at 4-8 hours after IANB, however the quality of the evidence was low/moderate due to risk of bias and heterogeneity. Further studies are recommended.

Effect of Premedication with Anti-inflammatory Drugs on Post-Endodontic Pain: A Randomized Clinical Trial

Abstract In spite of advances in root canal therapy and better knowledge of pulpal and periapical inflammation, up 40% of endodontic patients report varying degrees of pain. The aim of this present study was to compare the effect of single preoperative dose of ibuprofen or dexamethasone on post-endodontic pain. Sixty volunteers were divided into three groups (n=20 per group): PL, placebo; IB, 400 mg of ibuprofen; and DE, 8 mg of dexamethasone. The primary outcome was the post-endodontic pain intensity measured with a numerical rating scale (4, 8, 12, 24, and 48 h). Secondary outcomes included number of anesthetic cartridges used and consumption of rescue medication. Data were analyzed by one-way ANOVA, chi-square and Kruskal-Wallis tests. There was no significant difference among groups (p>0.05) considering the pain intensity. Only 37% of IB group patients and 28% of DE group patients used some rescue medication. On the other hand, 74% of PL group patients mentioned the consumption of rescue medication; PL group had a statistically significant difference (p<0.05) in comparison with IB and DE groups. The number of anesthetic cartridges used had no statistically significant difference among the groups (p>0.05). Significant differences were not found in the reduction of pain intensity and the number of anesthetic cartridges used. Considering the consumption of rescue medication (secondary outcome), preoperative administration of Ibuprofen or dexamethasone reduces post-endodontic pain and discomfort in comparison with a placebo. Premedication with anti-inflammatory drugs drugs could be contributed to control of the post-endodontic pain, mainly in patients more sensible for pain.

Effect of oral premedication on the anaesthetic efficacy of inferior alveolar nerve block in patients with irreversible pulpitis - A systematic review and network meta-analysis of randomized controlled trials

This systematic review (SR; PROSPERO database: CRD42017075160) and network meta-analysis (NMA) identified the most effective oral premedication for anaesthetic success of inferior alveolar nerve blocks (IANB) in cases of irreversible pulpitis. Medline and Ebscohost databases were searched up until 10/2017. Randomized controlled trials (RCT) studying the effect of oral premedication, alone or in combination, on the success of IANB for cases of irreversible pulpitis, compared to placebo or other oral premedications, were included. Quality of the included studies was appraised by the revised Cochrane risk of bias tool for randomized trials. Pairwise analysis, NMA and quality of evidence assessment using GRADE criteria were performed. Nineteen studies (n = 1654 participants) were included. NMA demonstrated that compared to placebo, dexamethasone was most effective in increasing anaesthetic success (RR, 2.92 [95% CI 1.74,4.91]; SUCRA = 0.96), followed by NSAIDs (RR, 1.92 [95% CI 1.63,2.27], SUCRA = 0.738) and Tramadol (RR, 2.03 [95% CI 1.18,3.49], SUCRA = 0.737). Premedication with acetaminophen added to NSAIDs demonstrated similar efficacy as NSAIDs alone (RR, 1.06 [95% CI 0.79,1.43]). Sensitivity analyses proved the superiority of dexamethasone or NSAIDs over any other premedications. Subgroup analyses of specific dosages in comparison with placebo demonstrated that dexamethasone 0.5 mg was most effective, followed by ketorolac 10 mg, piroxicam 20 mg, ibuprofen 400 mg + acetaminophen 500 mg and Tramadol 50 mg. Ibuprofen 400 mg, 600 mg and 800 mg had a significantly improved IANB success, while Ibuprofen 300 mg had no effect. Oral premedication with dexamethasone, NSAIDs or Tramadol significantly increased anaesthetic success. More trials are needed to evaluate the premedication effects of dexamethasone or Tramadol for improved anaesthetic success of IANB when treating irreversible pulpitis.

The effect of preoperative oral administration of prednisolone on postoperative pain in patients with symptomatic irreversible pulpitis: a single-centre randomized controlled trial

AIM

This single-centre randomized, double-blind, placebo-controlled clinical trial assessed the effect of a preoperative, single, oral dose of prednisolone on postoperative pain and postoperative analgesic intake in patients with symptomatic, irreversible pulpitis in mandibular molars.

METHODOLOGY

Four hundred participants, randomly assigned to two equal groups, received either 40 mg prednisolone or placebo tablets 30 min before single-visit root canal treatment. Patients recorded their pain level 6, 12 and 24 h after treatment on a 100-mm visual analogue scale. All patients received a sham capsule to take if needed as a postoperative analgesic, and, if the pain persisted, an analgesic was prescribed. The relative risk reduction and 95% confidence intervals (CI) were estimated for binary data. Mann-Whitney U-test was used to compare postoperative pain intensity between groups.

RESULTS

The relative risk reduction in pain incidence was 20.31% (95% CI: 12.03%, 27.82%) at 6 h, 23.39% (95% CI: 14.75%, 31.16%) at 12 h and 28.85% (95% CI: 18.08%, 38.20%) at 24 h. Prednisolone had significantly less post-obturation pain intensity compared to placebo at 6, 12 and 24 h (P < 0.001). The relative risk reduction in sham-capsule intake was 54% (95% CI: 38%, 66%) and of analgesic intake was 55% (95% CI: 3%, 79%). No adverse effects were recorded.

CONCLUSION

Preoperative oral administration of a single dose of 40 mg prednisolone was beneficial to control short-term post-obturation pain after single-visit root canal treatment in patients with symptomatic irreversible pulpitis reducing pain incidence after 24 h by approximately 30% and postoperative analgesic intake by approximately 55%.

Effect of Corticosteroids on Pain Relief Following Root Canal Treatment: A Systematic Review

INTRODUCTION

Post-operative pain and flare-up may occur in up to 58% of patients following root canal treatment. The aim was to conduct a systematic review and a possible meta-analysis to determine the effect of glucocorticosteroid (GCS) on pain following root canal treatment.

METHODS AND MATERIALS

Scopus, MEDLINE and CENTRAL databases were searched up to 30th January 2017 with broad key words. In addition, the reference lists in eligible papers and text books were hand-searched. Assessment of the eligibility of papers and data extraction were performed by two independent reviewers.

RESULTS

Of 9891 articles, 18 were recruited as eligible papers. Most of these papers showed pain reducing effect of GCS on post-endodontic pain. Because of wide heterogeneity among the recruited papers, it was not possible to perform meta-analysis.

CONCLUSION

Based on the results of this systematic review, there is a vast heterogeneity amongst articles regarding the use of GCS and their effect on post-operative pain after endodontic treatment. Further investigations with similar methods and materials are needed before meta-analysis on the effect of GCS on post-operative pain following root canal treatment can be performed.

Comparative evaluation of the efficacy of two modes of delivery of Piroxicam (Dolonex(®)) for the management of postendodontic pain: A randomized control trial

BACKGROUND

Alleviating pain is of utmost importance when treating patients with endodontic pain.

AIM

To compare and evaluate the efficacy of two modes of delivery of pretreatment Piroxicam (Dolonex(®), Pfizer) for the management of postendodontic pain.

MATERIALS AND METHODS

Sixty-six patients with symptomatic irreversible pulpitis were randomly divided into three groups of 22 subjects Group I - control group, no pharmacological intervention, Group II - patients received pretreatment oral Piroxicam (40 mg), Group III - patients received pretreatment intraligamentary injections totaling 0.4 mL of Piroxicam. Single visit endodontic therapy was performed by a single endodontist. Visual analogue scale was used to record pain before treatment and 4, 8, 12, 24, and 48 h postoperatively. Mann-Whitney U-test and Kruskal-Wallis tests were used to analyze the data.

RESULTS

The patients in Groups II and III perceived less postendodontic pain as compared to Group I (P < 0.05), at all the time intervals. At 12, 24, and 48 h, pain experience in patients of Group III was significantly less.

CONCLUSIONS

Intraligamentary mode of delivery of Piroxicam was more efficacious.

Effect of pretreatment diclofenac sodium on postendodontic pain: A randomised controlled trial

INTRODUCTION

Effective management of endodontic pain represents a continuing challenge. Many of the dental professionals are facing significant problems associated with postendodontic pain. Hence, the postendodontic pain has to be prevented at its primary stage without waiting for its occurrence. This trial was carried out to evaluate the use of a preoperative, single oral dose of diclofenac sodium for the prevention and control of postendodontic pain.

MATERIALS AND METHODS

Fifty patients were randomly assigned to two groups, placebo and diclofenac sodium (100 mg). The medications were administered 30 min before the start of standard endodontic treatment. Postoperative pain was assessed after 6, 12, and 24 h by using a visual analog scale.

RESULTS

Postendodontic pain showed a statistically significant difference between both groups at 6 and 12 h (P < 0.05) and there was no significant difference at 24 h.

CONCLUSION

Postendodontic pain was substantially reduced by preoperative administration of single oral dose of diclofenac sodium. It is thus possible to conclude that these favorable results might help to prevent postendodontic pain, especially in patients with a low pain threshold.

Efficacy comparison of periapical infiltration injection of dexamethasone, morphine and placebo for postoperative endodontic pain

OBJECTIVE

To evaluate the efficacy of periapical infiltration injection of dexamethasone and morphine in reducing postoperative endodontic pain.

METHOD

Ninety patients participated in this double-blind randomised controlled clinical trial. They were referred to the dental school of Shahid Beheshti Medical University, Tehran, Iran for conventional endodontic treatment of molar teeth. The canals of each tooth were completely prepared with cleansing and shaping. The patients were randomly divided into three experimental groups to receive dexamethasone, morphine or normal saline (1 mL). Patients were then instructed to complete a pain diary 4, 8, 24 and 48 h after the appointment. Statistical analysis consisted of chi-squared test, analysis of variance and Kruskal-Wallis test.

RESULTS

There was a statistically significant correlation between dexamethasone or morphine treatment and decreased levels and incidence of endodontic pain at 4, 8 and 24 h, but not at 48 h (P < 0.05). It was also observed that dexamethasone was significantly more effective (56.7% no pain) than morphine (43.3% no pain).

CONCLUSION

Periapical infiltration of dexamethasone and morphine led to a considerable decrease in postoperative endodontic pain during the first 24 h after operation. Dexamethasone was more effective than morphine in pain reduction.

Effect of pretreatment dexamethasone on postendodontic pain

OBJECTIVE

This study evaluates the use of a preoperative single oral dose of dexamethasone for the prevention and control of postendodontic pain.

STUDY DESIGN

Forty-seven patients were randomly assigned to 2 groups: placebo and dexamethasone (4 mg). The medications were administered 1 hour before the start of endodontic treatment. Postoperative pain was assessed after 4, 12, 24, and 48 hours.

RESULTS

Dexamethasone resulted in a statistically significant reduction in postendodontic pain at 4 and 12 hours (P < .05). However, no statistical difference (P > .05) was observed at 24 and 48 hours (Mann-Whitney test). The placebo group exhibited higher rescue medication intake (P < .05; Student t test). No side effects were reported for any of the medications used.

CONCLUSION

Preoperative single oral dose of dexamethasone substantially reduced postendodontic pain. Further studies are needed to evaluate the applicability of these findings to other clinical conditions and drug regimens.

Flare-ups in endodontics and their relationship to various medicaments

The purpose of this research is to investigate the frequency of endodontic flare-ups using a visual analogue scale. Definitions of flare-ups vary widely as does their reported frequency. A flare-up was defined as an increase of 20 or more points on the visual analogue scale for a given tooth, within the periods of 4 h and 24 h after the initial treatment appointment. The data from a previous study were used to determine the incidence of flare-ups after using three modalities (Ledermix, calcium hydroxide and no medication) to manage patients presenting for relief of pain of endodontic origin. A statistical analysis showed that there were no significant differences in flare-up rates at both the 4-h and 24-h periods between the three modalities. Further research is required using the above definition of a flare-up and standardising treatment protocols.

The Effect of Preoperative Acetaminophen or a Combination of Acetaminophen and Ibuprofen on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis

This study compared preoperative administration of acetaminophen or a combination of acetaminophen and ibuprofen versus placebo for potential increased effectiveness of inferior alveolar nerve (IAN) block anesthesia. There were 40 patients with irreversible pulpitis randomly assigned to a drug or placebo group. Thirty minutes after ingestion of medication, an IAN block was administered. A cold test was done 15 minutes after the block, and if the patients had no sensitivity, endodontic therapy was initiated. If the patient had no pain on access, the IAN was recorded as successful. If the patient had sensitivity to cold or to the access procedure, it was recorded as a failure. Overall success was 60% for all three groups. Success was 71.4% for the acetaminophen group, 75.9% for the acetaminophen and ibuprofen group, and 46.2% for the placebo group. There was no significant difference between the groups; however, there was a trend toward higher success in the medication groups.

Effects of pre-emptive morphine, ibuprofen or local anesthetic on fos expression in the spinal trigeminal nucleus following tooth pulp exposure in the rat

In the present study, we used Fos expression as an index of nociceptive input to the spinal trigeminal nucleus after exposure of the coronal pulp tissue of maxillary right first molars and examined the effects of pretreatment with an opioid, a nonsteroidal anti-inflammatory drug or a local anesthetic before pulp exposure. Exposure of the tooth pulp produced a significant increase in Fos-like immunoreactivity in the superficial laminae of subnucleus caudalis; pretreatment with a control infiltration injection of saline directly above the maxillary molar 30 min before pulp exposure had no effect on Fos expression. Pretreatment with morphine 30 min before pulp exposure dose-dependently (2.5, 5, and 10 mg/kg subcutaneously) reduced Fos expression in subnucleus caudalis whereas pretreatment with ibuprofen (10-100 mg/kg subcutaneously) did not significantly affect Fos expression. Local anesthetic pretreatment was effective in reducing Fos expression only for the long acting bupivacaine; lidocaine without and with epinephrine (1:100,000) failed to significantly affect Fos expression. These results suggest that pre-emptive opioid treatment can decrease postoperative central nervous system changes associated with tooth pulp injury, and therefore, may decrease postoperative pain. Given the effects of local anesthetic on Fos expression, a combination of long acting local anesthetic with pre-emptive opioid would likely be most efficacious in decreasing postoperative dental pain.

Pain reduction in untreated irreversible pulpitis using an intraosseous injection of Depo-Medrol

The purpose of this prospective, double-blind, randomized study was to evaluate pain reduction using an intraosseous injection of slow-releasing methylprednisolone in teeth with irreversible pulpitis. Forty subjects presenting for emergency treatment completed the study. Each subject had a tooth with a clinical diagnosis of irreversible pulpitis with actively associated moderate to severe pain. After local anesthesia was attained, the subjects were randomly assigned to receive an intraosseous injection of either 1.0 ml of Depo-Medrol (40 mg) or 1.0 ml of sterile saline (control). No endodontic therapy was begun at the initial appointment. The subjects received ibuprofen and Tylenol #3 and completed a 7-day questionnaire on pain, percussion pain, and analgesic medications taken each day. Over the 7-day observation period, the subjects who received the intraosseous injection of Depo-Medrol reported significantly (p < 0.05) less pain and percussion pain while taking significantly (p < 0.05) fewer pain medications. Clinically the intraosseous injection of Depo-Medrol could be used to temporarily alleviate the symptoms of irreversible pulpitis until definitive treatment can be rendered.

Effects of pre-emptive local anaesthesia on tooth pulp deafferentation-induced neuroplastic changes in cat trigeminal brainstem neurones

Previous work has shown increased excitability of brainstem neurones in the trigeminal (V) subnucleus oralis following the deafferentation produced by tooth-pulp removal. The present study was designed to determine if the changes in oralis neuronal properties seen in cats 1-2 wk after the deafferentation could be blocked by local anaesthesia of the Vth nerve proximal to the sites of pulp injury just before the actual deafferentation. The response properties of neurones recorded in V subnucleus oralis were determined in anaesthetized cats. One or two weeks before neuronal recording, the pulps of the posterior mandibular teeth were removed under local mandibular anaesthesia in one group of cats (group A) and without local anaesthesia in a second group (group B); a third group (group C) had no pulp removal but received local anaesthesia. Consistent with the earlier data, there was a significantly increased incidence of neurones having an enlarged mechanoreceptive field, spontaneous activity and habituating tap sensitivity in group B compared to group C, but no significant differences were found between the two deafferented groups (A and B). As local anaesthesia did not prevent the development of pulp deafferentation-induced changes in the oralis neurones, it is unlikely that an afferent barrage of impulses induced by the deafferentation procedure was responsible for the neuroplastic changes that subsequently developed in the V subnucleus oralis.

Periapical neural changes after pulpectomy

Pulpectomy and pulpal necrosis result in severance of the nerves that supply the pulp as well as loss of their target organ. Inflammatory changes commonly extend into the periapical region to involve those nerves. The neural response to pulpal loss combined with periapical inflammation is a derangement of the periodontal plexus normally located in the center of the periodontal space around the apical third of the root; the result is the formation of a disorganized group of sprouting and branching axons that have some features in common with neuromas. The inflammatory and neural responses continue for at least a year even when pulpectomy is followed by canal debridement and obturation. Then the responses are reduced but not eliminated by steroids. Root canal therapy with techniques that do not leave residual inflammation still results in increased periapical innervation; the increase seems to be an organized addition to the normal periradicular plexus.

Distribution of injected dexamethasone from the buccal vestibule of the rat mandible

Thirty-six Sprague-Dawley rats were divided into three groups of 12. Group 1 was a control, whereas group 2 had the dental pulp of the first mandibular molar acutely exposed, and group 3 had dental pulp exposure for 10 days. All animals were injected with 125I-labeled dexamethasone phosphate into the right mandibular vestibule. Each group of 12 was divided into subgroups of 4 and sacrificed at 1, 2, or 4 h. The soft tissue on the buccal side and the mandible with the molars were collected and the radioactivity determined. Dexamethasone was absorbed from the injection site and distributed to the ipsilateral mandible and to the contralateral muscle and bone similarly, regardless of the treatment. Results also indicate a possible osseous affinity for this steroid, which could be beneficial in relieving the pain of intraosseous endodontic flare-ups.

Intraligamentary injection of slow-release methylprednisolone for the prevention of pain after endodontic treatment

The intraligamentary injection of a slow-release steroidal, the anti-inflammatory agent slow-release methylprednisolone (Depomedrol), was compared to a placebo and to an active placebo (Mepivacaine) in preventing postoperative pain after root canal treatment. The results clearly demonstrated that the tested drug significantly reduced the frequency and intensity of postoperative pain sequelae in the experimental set-up.

Anti-inflammatory effects of dexamethasone on periapical tissues following endodontic overinstrumentation

An animal model was developed in which the anti-inflammatory effects of dexamethasone could be examined histologically in periapical tissues following endodontic overinstrumentation. Mandibular first molars containing vital or partially necrotic pulp tissue were instrumented beyond the apical foramen in rats. Fifty microliters of sterile saline or dexamethasone sodium phosphate (0.4 mg/ml) were administered in a blind manner by supraperiosteal infiltration into the buccal vestibule. The rats were killed after 6, 24, and 48 h. Block sections of the mandibular molars were processed for histological examination and stained with hematoxylin and eosin. The number of polymorphonuclear neutrophils present in the periapical tissues was counted in a blind manner and statistical analysis of the results was performed by two-way analysis of variance. Following endodontic overinstrumentation, local infiltration of dexamethasone produced a significant anti-inflammatory effect on the periapical tissues of teeth with vital or partially necrotic pulp tissue.

Effect of variable doses of dexamethasone on posttreatment endodontic pain

One hundred six patients with pretreatment pain presenting for endodontic treatment participated in a controlled double blind study. After root canal therapy, the patients were given an intraoral intramuscular injection of either a saline placebo or various dosages of dexamethasone. Posttreatment pain incidence and severity were evaluated at 4, 8, 24, 48, and 72 h. Injection of the various dosages of dexamethasone, taken as a group, was shown to significantly reduce the severity of pain at 4 and 8 h, and 0.07 to 0.09 mg/kg dosage alone significantly reduced pain at 8 h. Patients who received dexamethasone took significantly fewer posttreatment pain medications than those who received the placebo. Although there was a trend toward a reduction in the incidence of posttreatment pain for patients who received dexamethasone, the difference was not statistically significant.

Dexamethasone as an adjunct in oropharyngeal obstruction in a patient with leukemia

Incipient airway obstruction due to fulminating bacterial infection of pharyngeal tissues requires prompt and definitive intervention. A case is presented in which dexamethasone was a key adjunct to antibiotic therapy in averting this problem in a severely neutropenic patient with acute leukemia.

Comparison of prophylactic and on-demand diflunisal for pain management of patients having one-visit endodontic therapy

To determine whether the posttreatment prophylactic use of diflunisal (Dolobid 500) would be more effective than the on-demand use of diflunisal in reducing endodontic posttreatment pain, the current open-label, randomized study was undertaken. After one-visit nonsurgical endodontic therapy, 100 patients with asymptomatic teeth having either vital-inflamed pulp, pulpal necrosis, or pulpal necrosis with periapical radiolucent lesion were randomly given either prophylactic diflunisal (two tablets immediately at the conclusion of the visit, then four tablets to be taken in the schedule of one every 8 to 12 hours for pain if needed) or on-demand diflunisal (same dosage schedule; pills to be taken only if needed). The outcome showed that compared to the on-demand usage, the posttreatment prophylactic administration of diflunisal resulted in a statistically significant reduction in the number of episodes of endodontic posttreatment pain that required analgesic intervention. It appears from the results of this study that the posttreatment prophylactic use of diflunisal is significantly more effective than the on-demand usage of diflunisal in reducing endodontic posttreatment pain for one-visit endodontic therapy with all types of originally asymptomatic endodontic conditions. Further studies are necessary to determine whether pretreatment prophylactic deflunisal would be more effective, and also the effectiveness of prophylactic diflunisal in reducing posttreatment pain in presenting symptomatic cases and for cases treated in multiple visits.