Evaluation of Pretreatment Analgesia and Endodontic Treatment for Postoperative Endodontic Pain

Influence of Diclofenac Potassium versus Prednisolone on Postendodontic Pain and Pulpal Interleukin-8 Expression in Symptomatic Irreversible Pulpitis Cases: A Randomized Placebo-controlled Trial

AIM

This prospective, randomized, double-blind clinical trial investigated the impact of diclofenac potassium, prednisolone, and placebo as oral premedication on postendodontic pain and pulpal interleukin (IL)-8 expression in patients with irreversible pulpitis.

METHODS

Thirty-six patients undergoing conventional endodontic treatment were assigned into one of 3 groups (n = 12). Pulpal blood samples were taken after access cavity preparation and stored until they were analyzed using enzyme-linked immunosorbent asssay for quantification of IL-8. Postendodontic pain was scored using the visual analogue scale. Outcome data were statistically analyzed using one-way analysis of variance, Kruskal-Wallis, Friedman's, Dunn's, Chi-square, and Fisher's exact tests and Spearman's correlation coefficient. The significance level (α) was set at 0.05.

RESULTS

Apart from preoperative pain scores, all groups had similar baseline characteristics (P > .05). Immediate postendodontic pain scores had a significant difference between all groups (P < .05) where placebo group showed the highest score. There was no significant difference between all groups at 6 and 12 hours postoperatively (P > .05). Furthermore, there was no significant difference in the incidence of postendodontic pain and in mean IL-8 levels between the 3 groups (P > .05).

CONCLUSIONS

The only impact the premedications had was on the immediate postendodontic pain intensity, and they had no influence on the later time points, incidence of postendodontic pain or pulpal IL-8 levels.

Postoperative pain after single-visit root canal treatments in necrotic teeth comparing instruments' kinematics and apical instrumentation limits - a prospective randomized multicenter clinical trial

OBJECTIVES

This prospective randomized multicenter clinical trial (PRMCT) investigated postoperative pain after single-visit root canal treatments in teeth affected by pulp necrosis (PN), and asymptomatic apical periodontitis (AAP) (with apical radiolucent areas) or normal periradicular tissues (without apical radiolucent areas) comparing different instruments' kinematics and apical instrumentation limits.

METHODS

Before chemomechanical preparation, 240 patients/teeth were randomly distributed into four groups (n = 60) according to the instruments' kinematics (rotary or reciprocating) and apical instrumentation limits (with or without intentional foraminal enlargement [IFE]). After that, specimens were submitted to the same irrigation and obturation techniques, and the patients were referred to undergo the definitive restorations. No medication was prescribed, but the patients were instructed to take either paracetamol (750 mg every 6 h for three days) or ibuprofen (600 mg every 6 h for three days) in pain cases. Postoperative pain incidence and levels were assessed at 24-, 48-, and 72 h following treatment completion according to a verbal rating scale (VRS) following a score. The Kolmogorov-Smirnov test was applied to assess the normality of the data. Mann-Whitney U, Chi-square, Friedman's ANOVA, and Friedman's multiple 2 to 2 comparison tests were employed to identify potential significant statistical differences among the variables in the study groups (P < .05).

RESULTS

Significant statistical differences were only observed among the groups considering tooth, periradicular status, and the occurrence of overfilling (sealer extrusion) (P < 0.00). Patients with teeth instrumented through rotary kinematics and without IFE experienced lower rates of postoperative pain; however, this difference was relevant only at 24 h (P < 0.05).

CONCLUSIONS

Postoperative pain was lower after using a rotary file system (Profile 04) inserted up to the apical constriction (AC). However, this finding was just statistically meaningful at 24 h.

TRIAL REGISTRATION

This PRMCT was approved by the Human Research Ethics Committee of the Paranaense University - UNIPAR, Francisco Beltrão, PR, Brazil (CAAE. 46,774,621.6.0000.0109) on 02/09/2021. It was registered at The Brazilian Registry of Clinical Trials - ReBEC (RBR-3r967t) on 01/06/2023, was performed according to the Principles of the Helsinki Declaration and is reported following the Consolidated Standards of Reporting Trials Statement.

Can diode laser 810 nm decrease post endodontic pain in patients with asymptomatic necrotic maxillary incisors? A four-arm randomized controlled trial

AIM

To find the best method for applying the diode laser 810 nm to relieve post-endodontic pain on necrotic maxillary incisors with periapical lesions within a single-visit treatment.

METHODS

Eighty patients with a necrotic incisor, diagnosed with asymptomatic apical periodontitis, received standardized cleaning and shaping procedures, then divided randomly with a 1:1:1:1 allocation ratio into four groups: Group 1: control group with no laser application, Group 2: applying the diode laser as an irrigation activation system (IAS), Group 3: applying the diode laser from the buccal and palatal mucosa, Group 4: applying the diode laser as an IAS and from buccal and palatal mucosa. The postoperative pain was assessed using the visual analog scale (VAS) 1, 3, 7, and 14 days after the treatment. The mean values of the VAS score were statistically analyzed used Kruskal-Walis and Mann-Whitney U tests. The level of significance was set at a = 0.05.

RESULTS

During 14 days after treatment, there was a statistically significant difference between mean values of VAS scores in the four groups (P value < 0.05); Group 1 scored the highest score, whereas Group 4 showed the lowest one. Moreover, Group 4 showed favorable outcomes compared with Group 2 and Group 3 during the first three days after treatment.

CONCLUSION

Diode laser reduced postoperative pain after necrotic teeth with large-sized apical lesion treatment, whereas using diode laser either as an IAS or LLLT reduced the postoperative pain compared with the control group. Moreover, the usage of a diode laser in both previous techniques represents the best protocol for postoperative pain relief during 14 days of treatment.

CLINICAL RELEVANCE

The clinical significance of this study is to investigate the best method to reduce postoperative pain using diode lasers 810 nm; where the results of this study indicated that the more diode laser exposer in LLLT and IAS, the less postoperative pain after endodontic procedures.

Clinical Assessment of Preemptive Analgesia on Success of Pulpal Anesthesia and Postendodontic Pain in Children with Irreversible Pulpitis: A Randomized Comparative Study

Introduction

Optimal pain management of symptomatic pulpitis in formative years goes a long way in developing a positive dental attitude. Efforts should be made to increase the success of anesthesia, thus diminishing negative dental experiences. The aim of the study was to assess the efficacy of preemptive analgesia on the success of pulpal anesthesia following inferior alveolar nerve block (IANB) in children with symptomatic irreversible pulpitis and on reducing postendodontic pain.

Materials and methods

The research design was an in vivo, three-group, parallel, quadruple-blind study. A total of 75 patients were randomly allocated to one of the three groups-group I: ibuprofen, group II: combination of ibuprofen and paracetamol, and group III: multivitamin (placebo). Premedication was given 45 minutes before treatment, and patients received IANB in a standardized manner. Pain during pulpectomy was recorded using the face, legs, activity, cry, consolability (FLACC) scale and postoperatively using Wong-Baker's pain rating scale (WBPRS) at 4, 12, and 24 hours. Success was measured if the pain felt was of no or mild intensity.

Results

Success of IANB was 64% for ibuprofen, 72% for the combination group, and 40% for the placebo group, with no statistically significant difference between all groups (p = 0.06) on the FLACC scale. At 4 hours postoperatively, a significant difference (p = 0.02) was found among groups with more children experiencing no or mild pain in groups I and II and the highest number of rescue medications taken by the placebo group.

Conclusion

Ibuprofen and a combination of ibuprofen and acetaminophen as preemptive analgesics had no significant effect on the success rate of IANB, although it was effective in reducing pain at 4 hours postoperatively.

How to cite this article

Gori NA, Patel MC, Bhatt RK, et al. Clinical Assessment of Preemptive Analgesia on Success of Pulpal Anesthesia and Postendodontic Pain in Children with Irreversible Pulpitis: A Randomized Comparative Study. Int J Clin Pediatr Dent 2024;17(1):72-78.

Clinical correlation of salivary alpha-amylase levels with pain intensity in patients undergoing emergency endodontic treatment

BACKGROUND

Pain is usually subjective and thus it is challenging to describe its characteristics such as nature, intensity, and origin. Non-invasive methods such as assessing salivary alpha-amylase (SAA) may aid the practitioner to evaluate the pain intensity. Hence, the current study aimed to correlate the levels of SAA with the pain intensity in patients presenting with varied endodontic pain levels.

METHODS

Sixty patients who presented with varied intensities of endodontic pain were selected for the present study out of which seven patients were excluded/dropped, leaving a total sample of fifty-five patients for assessment. Mandibular molar with symptomatic irreversible pulpitis without periapical pathology were included in the study. A 5ml of un-stimulated was obtained from the patients, following which the local anesthesia was administered. Root canal treatment was then performed and the pain scores at pre-operative and post-operative were recorded. Additionally, salivary samples were collected after emergency endodontic treatment and sent for sialochemical analysis. IBM.SPSS statistics software 23.0 was employed to assess the obtained data.

RESULTS

A statistically significant drop in the pain score (P < 0.001) and SAA levels (P < 0.001) were observed post-operatively in the contract to pre-operative state. A strong positive correlation was reported between SAA levels and pain scores in patients undergoing emergency endodontic treatment at both time intervals namely pre-operative (P < 0.001) and post-operative (P < 0.001).

CONCLUSION

The results of this preliminary showed a strong association between the pain score and SAA levels in patients undergoing an emergency endodontic treatment.

Analgesic Efficacy of Ketoprofen Transdermal Patch versus Ibuprofen Oral Tablet on Postendodontic Pain in Patients with Irreversible Pulpitis: A Randomized Clinical Trial

Materials and Methods

In this randomized clinical trial, 64 patients who had mandibular first and second molars with irreversible pulpitis were randomly divided into two groups (n = 32) by stratified permuted block randomization. The experimental group used 60 mg KTP every 6 hours, and the control group received 400 mg ibuprofen tablets every 6 hours for 1 day. The severity of pain experienced by patients was quantified before and at 2, 4, 8, 12, 24, and 48 hours after endodontic treatment, using the numerical rating scale (NRS). Data were analyzed by using the t-test, Mann-Whitney test, and generalized estimating equation (GEE) (alpha = 0.05).

Results

The pain score was not significantly different between the two groups at the baseline or any other postoperative time point (P > 0.05). The reduction in the pain score was significant in both groups from 2 to 10 hours and 10 to 48 hours, postoperatively (P < 0.001). The interaction effect of time and group was not significant on the postoperative pain score in the abovementioned time intervals, and the pattern of pain reduction was the same over time in both groups (P > 0.05).

Conclusion

Both KTP and ibuprofen effectively decreased postendodontic pain. Considering the comparable pattern of pain reduction, KTP can be used as an alternative to ibuprofen tablets for effective pain control after endodontic treatment of mandibular first and second molars with irreversible pulpitis.

Comparison of pretreatment gabapentin and pregabalin to control postoperative endodontic pain - a double-blind, randomized clinical trial

BACKGROUND

Postoperative endodontic pain is an enigma for the dentist. This study aimed to evaluate the analgesic effect of 300 mg gabapentin or 75 mg pregabalin in reducing postoperative endodontic pain compared with a placebo.

METHODS

Ninety patients who needed root canal treatment with an initial numerical rating scale (NRS) pain score of > 4 (T0) were randomly divided into three groups (n=30). Patients were then administered either 300 mg gabapentin (group A), 75 mg pregabalin (group B), or a placebo (group C) 30 min prior to the start of endodontic treatment. A single operator performed single-visit endodontics, and pain was evaluated immediately after endodontic treatment (T1) and at 4 h (T2), 8 h (T3), 12 h (T4), 24 h (T5), 48 h (T6), and 72 h (T7) using the NRS. Ibuprofen/paracetamol (400 mg/325 mg) was administered as a rescue dose if needed.

RESULTS

Pregabalin performed significantly better when compared with gabapentin at all time points except at 72 h after treatment (P=0.170). The placebo group showed significantly higher pain scores than the other two groups. The percentage of pain relief was maximum for pregabalin (92.1%), followed by gabapentin (87.6%) and placebo (69.1%) at 72 h after treatment completion.

CONCLUSION

This study showed that pretreatment with a single dose of pregabalin and gabapentin both had greater analgesic effects than a placebo. They can be effectively used to reduce postoperative endodontic pain.

Anesthetic efficacy of supplemental buccal infiltration versus intraligamentary injection in mandibular first and second molars with irreversible pulpitis: a prospective randomized clinical trial

Background

To compare the anesthetic efficacy of supplemental buccal infiltration (BI) (1.7 ml) versus intraligamentary (IL) injection containing 0.4 ml of 4% articaine with 1:100.000 epinephrine after an inferior alveolar nerve block (IANB) with 1.7 ml 2% lidocaine in the first and second mandibular molars diagnosed with irreversible pulpitis (IP).

Methods

One hundred subjects diagnosed with IP of either the mandibular first (n = 50) or second molars (n = 50) and failed profound anesthesia following an IANB were selected. They randomly received either the IL or BI techniques of anesthesia. Pain scores on a 170 mm Heft-Parker visual analog scale were recorded initially, before, and during supplemental injections. Furthermore, pulse rate was measured before and after each supplemental injection. During the access cavity preparation and initial filing, no or mild pain was assumed to indicate anesthetic success. The chi-square test, Mann-Whitney U test, and independent samples t-test were used for the analyses.

Results

The overall success rates were 80% in the IL group and 74% in the BI group, with no significant difference (P = 0.63). In the first molars, there was no significant difference between the two techniques (P = 0.088). In the second molars, IL injection resulted in a significantly higher success rate (P = 0.017) than BI. IL injection was statistically more successful (P = 0.034) in the second molars (92%) than in the first molars (68%). However, BI was significantly more successful (P = 0.047) in the first molars (88%) than in the second molars (64%). The mean pulse rate increase was significantly higher in the IL group than in the BI group (P < 0.001).

Conclusions

Both the IL and BI techniques were advantageous when used as supplemental injections. However, more favorable outcomes were observed when the second molars received IL injection and the first molars received BI.

Effect of Ultrasonic and Diode Laser Irrigation Activation on Post-operative Pain and Microbial Reduction in Single Visit Endodontic Treatment of Necrotic Mandibular Molars

Aim: To clinically evaluate the effect of continuous ultrasonic and diode laser 810 wave length irrigation activation techniques on postoperative pain and bacterial reduction in single visit endodontic treatment of mandibular molars. Material and methods: Forty patients requiring root canal treatment therapy for necrotic mandibular molars teeth were included in this study with age ranges between 20 and 45 years. In all cases, single visit endodontic treatment was carried out using Revo-S rotary file system in crown down sequence. NaOCl 2.5% irrigation solution was used during treatment. Patients were randomly and equally assigned into two groups according to irrigation technique. Group (1): conventional syringe irrigation and group (2): continuous ultrasonic irrigation. Each group was subdivided into two sub groups (n = 10); subgroup 1A (conventional syringe irrigation with no laser), subgroup 1B (conventional syringe irrigation with diode laser), subgroup 2A (continuous ultrasonic irrigation with no laser) and subgroup 2B (continuous ultrasonic irrigation with diode laser). Postoperative pain evaluation was done using Visual Analogue Scale (VAS) at 6, 12, 24, 36, 48 hours and 7 days postoperatively. Microbiological detection of bacterial reduction was done by taking Samples (S1 and S2) for bacterial cultures. S1 after finishing access cavity and before mechanical preparation and S2 after finishing mechanical preparation and irrigation activation and before obturation. Samples were cultured on blood agar and determined as colony forming units (CFU/mL). Microbiological bacterial reduction was calculated accordingly.  Statistical analyses were analyzed using the Mann-Whitney U test.  The significance level was set at p < 0.05. Results: In all sub groups, postoperative pain decreased by time in all time intervals but pain was significantly lower in subgroup (2B) (continuous ultrasonic irrigation with diode laser) than subgroup (1A) (conventional syringe irrigation with no laser) in all time interval. Microbiological results showed the highest bacterial reduction was in subgroup (2B) (continuous ultrasonic irrigation with diode laser) and least bacterial reduction was in subgroup (1A) (conventional syringe irrigation with no laser). Conclusion: Using diode laser and continuous ultrasonic irrigation activation techniques as adjunctive methods showed improvement in postoperative pain records and enhanced bacterial reduction in root canal therapy. Keywords: Continuous ultrasonic irrigation, diode laser 810, post-operative pain, bacterial reduction, single visit endodontic treatment.

Comparative evaluation of the effect of two pulpal medicaments on pain and bleeding status of mandibular molars with irreversible pulpitis post-failure of inferior alveolar nerve block: a double-blind, randomized, clinical trial

Background

Complete relief of pain due to irreversible pulpitis is challenging to obtain with analgesic medications. The high incidence of an inferior alveolar nerve block (IANB) failure makes it difficult for practitioners to perform endodontic treatment without implementing other anesthetic techniques, especially mandibular molars. The aim of this study was to compare efficacies of two different quantities of paraformaldehyde based pulpal medicaments to relieve the pain and control hyperemic pulp post-failure of IANB and supplementary technique in patients experiencing this symptomatic irreversible pulpitis in the permanent mandibular tooth.

Method

Eighty-two participants with severe pain pre-operatively (Heft Parker Visual Analogue Scale, VAS > 114 mm) were enrolled, and pain responses were recorded at different time intervals using the Heft Parker visual analogue scale. To the patients experiencing pain even after the administration of the standard IANB and supplemental intraligamentary injection, one of the two paraformaldehyde based pulpal medicaments was placed in the pulp chamber and sealed. Participants were recalled after 24-48 h (second visit) to assess pain and bleeding reduction.

Results

Results showed a significant decrease in pain severity and bleeding score post medicament placement (p < .05). Hence judicious use within a recommended period, pulpal medicaments can be considered safe.

Conclusion

Paraformaldehyde based pulpal medicament can be used as an alternative to manage pain in patients having severe irreversible pulpitis and hyperalgesia.

Analgesic efficacy of corticosteroids and nonsteroidal anti-inflammatory drugs through oral route in the reduction of postendodontic pain: A systematic review

Analgesic medications in dentistry are indicated for the relief of acute pain, postoperative pain, chronic pain as well as controlling adjunctive intraoperative pain. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has shown an effective reduction of postendodontic pain by action on the cyclooxygenase pathway. Another medication which is used recently is corticosteroid which enables the reduction of pain. They are hormones secreted from the adrenal gland and have strong anti-inflammatory actions. This review aims to compare the analgesic efficacy of NSAIDs and corticosteroids when administered through oral route for reducing postendodontic pain. The secondary objective was to assess the anesthetic effect of the nerve block when an oral premedication of NSAIDs or corticosteroids was administered. The databases of PubMed, ScienceDirect, LILACS, and Cochrane were searched for related topics from 1983 to April 2020. Bibliographies of clinical studies were identified in the electronic search. Clinical studies with postendodontic pain reduction using NSAIDs and corticosteroids were selected. Clinical studies that met all inclusion criteria were reviewed. Data extraction was performed independently by two reviewers. All individuals who administered single dose analgesic (NSAID or corticosteroid) before initiating root canal treatment were taken into inclusion criteria. All the relevant data were extracted from the selected studies were reviewed by two independent reviewers using a standardized data collection form, and in case of disagreement, a third reviewer was enquired to achieve a consensus. Risk of bias of the selected studies was done using Cochrane Risk of Bias Tool (version 1). Mean pain score levels at various time intervals showed an increased analgesic success rate for corticosteroids ( 32-1) in comparison to NSAIDs ( 32-21.4). Anesthetic effect of the nerve block administered was seen to be better when an oral premedication of corticosteroids (38.2%–80.8%) was given in comparison to NSAID (25.5%–73.1%). From the present study, it can be concluded that oral administration of corticosteroids provides a better analgesic efficacy when compared to NSAIDs as an oral premedication for postoperative pain reduction. It can also be concluded that corticosteroids when used as an oral premedication provide a better anesthetic effect of the nerve block administered when compared to NSAIDs given as an oral premedication. These findings could help the clinician determine which pretreatment analgesic would have a better effect in reduction of pain posttreatment as well as increasing the anesthetic efficacy of administered block. Systematic Review Registration Number: CRD42021235394.

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.

Evaluation of Ozone Therapy in Endodontic Treatment of Teeth with Necrotic Pulp and Apical Periodontitis: A Randomized Clinical Trial

INTRODUCTION

The aim of this study was to compare the effect of different application techniques of ozone on the prevalence of postendodontic pain in patients undergoing single-visit root canal treatment.

METHODS

hundred eight patients with necrotic pulp in single-rooted teeth and apical periodontitis participated in the trial. A standard single-visit endodontics protocol was followed with 5.25% sodium hypochlorite and rotary nickel-titanium files. After shaping and cleaning, patients were randomly allocated into the following groups: group 1 (n = 21), ozone treatment with no activation (NA); group 2 (n = 22), ozone treatment with manual dynamic activation (MDA); group 3, (n = 21), ozone treatment with passive ultrasonic activation (PUA); group 4 (n = 23), ozone treatment with sonic activation (SA); and group 5 (n = 21), no ozone treatment (the control group). Patient levels of discomfort were recorded at 6 different time intervals using the visual analog scale (VAS). Comparison of the mean difference between the groups and time intervals was performed using 2-way analysis of variance followed by a post hoc Bonferroni test. The level of significance was set at 5%.

RESULTS

VAS scores were highest for the control > NA > MDA > SA > PUA groups. A statistically significant reduction in VAS scores was observed in the PUA and SA groups in comparison with the NA, control, and MDA groups. Timewise comparison showed a highly significant decline in VAS scores at all time intervals (P < .001).

CONCLUSIONS

Ultrasonic and sonic activation of ozone resulted in less pain in patients undergoing single-visit endodontics compared with no ozone treatment.

Postoperative pain after endodontic treatment of necrotic teeth with large intentional foraminal enlargement

Objectives

To evaluate postoperative pain after endodontic treatment of necrotic teeth using large intentional foraminal enlargement (LIFE).

Materials and Methods

The sample included 60 asymptomatic necrotic teeth (with or without chronic apical periodontitis), and a periodontal probing depth of 3 mm, previously accessed and referred to perform endodontic treatment. After previous procedures, the position and approximate size of the apical foramen (AF) were determined by using an apex locator and K flexo-files, respectively. The chemomechanical preparation was performed with Profile 04 files 2 mm beyond the AF to achieve the LIFE, using 2.5 mL of 2.5% NaOCl at each file change. The filling was performed by Tagger's hybrid technique and EndoFill sealer. Phone calls were made to all the patients at 24, 48 and 72 hours after treatment, to classify postoperative pain. Statistical analysis was performed by different tests with a significance level of 5%.

Results

Age, gender, periradicular status and tooth type did not influence postoperative pain (p > 0.05). Only 1 patient (1.66%) reported severe pain after 72 hours. Moderate pain was reported by 7, 4 and 3 patients after 24, 48 and 72 hours, respectively (p = 0.0001). However, paired analyses showed a statistically significant difference only between 24 and 72 hours (p = 0.04). Sealer extrusion did not influence the postoperative pain (p > 0.05).

Conclusions

Acute or moderate postoperative pain was uncommon after endodontic treatment of necrotic teeth with LIFE.

Trial Registration

The Brazilian Clinical Trials Registry Identifier: RBR-3r967t

Effect of low-level laser therapy on postoperative pain after single-visit root canal retreatment of mandibular molars: A randomized controlled clinical trial

AIM

To compare the effect of low-level laser therapy (LLLT) on postoperative pain after single-visit root canal retreatment on mandibular molars.

METHODOLOGY

This randomized controlled clinical trial included 36 patients referred to the Department of Endodontics, Islamic Azad University, Tehran, Iran. Healthy patients who required root canal retreatment on symptomatic first or second mandibular molars, with a PAI index score of 2 or 3, preoperative tooth and percussion pain of <56 mm on a 170-mm visual analogue scale (VAS) were included. After local anaesthesia using inferior alveolar nerve block followed by rubber dam isolation and access cavity preparation, the D RaCe retreatment system was used to remove the existing root filling material, and after canal negotiation and gaining patency, working length was determined with an apex locator. Further canal enlargement was carried out with size 35, 0.04 taper, and size 40, 0.04 taper RaCe rotary instruments and then canals were filled using laterally compacted gutta-percha points and AH Plus sealer. The patients were randomly assigned to treatment groups: In the LLLT group, a 980-nm diode laser set at 6.89 W/cm² energy density, 0.5 W power, and a tip diameter of 10 mm were activated from the buccal side on the mesial and distal root apices for 15 s. In the sham group, the laser handpiece was placed inside the patient's mouth at the same location, but the laser was not activated. Then patients were instructed to record their postoperative pain levels at 4, 8, 12 and 24 h and 2, 3 and 7 days after treatment on separate VAS scales. For data analysis, the independent sample t and the Mann-Whitney U tests were used. Nominal variables were analysed by using the chi-square test.

RESULTS

In the LLLT group, the most intense pain was reported 24 and 48 h post-treatment [mean (SD) = 0.22 (0.54) for both], whereas in the sham group, the most intense pain level was observed 4 h post-treatment [mean (SD) = 0.78 (0.80)]. At the 4-h interval, pain intensity was significantly lower in the LLLT group (p = .016).

CONCLUSIONS

Low-level laser therapy reduced postoperative pain after single-visit root canal retreatment of mandibular molars only four hours following the procedure.

Medications Used for Prevention and Treatment of Postoperative Endodontic Pain: A Systematic Review

Objective:

Prevention and management of postoperative endodontic pain is a common challenge for the endodontists. This systematic review was conducted to evaluate the efficacy and safety of medicament therapeutic protocols in the prevention and management of endodontic pain.

Methods:

A literature search was undertaken in MEDLINE, Cochrane Library, LILACs, and SciELO, for articles published until December 2017, without year restriction and written only in English. An additional search was performed in the references of the retrieved studies.

Study eligibility criteria, participants, and interventions: The inclusion criteria were randomised clinical trials that evaluated the use of medications to prevent or control moderate to severe pain in adult patients, using a visual analog scale as a tool for pain measurement. The primary outcome evaluated was the reduction of pain scores. The second outcome evaluated was the need for additional analgesia and the occurrence of adverse events.

Study appraisal and synthesis methods: The quality assessment of the included studies was performed following the Jadad scale to measure the likelihood of bias in pain research reports.

Results:

After removing duplicates and excluding the studies that did not meet the selection criteria, ten studies were included tin the systematic review. Among these studies, five studies administered the medications before the endodontic procedures and five studies after. These studies evaluated non-opioid analgesics (acetaminophen), opioid analgesics (tramadol and codeine), nonsteroidal anti-inflammatories (ibuprofen, flurbiprofen, ketorolac tromethamine, etodolac, tenoxicam, and naproxen), steroidal anti-inflammatory (prednisolone) or the association of medications to prevent or control postoperative pain. It was possible to establish a significant relationship between the use of additional analgesics and periapical diagnosis. Adverse events were not observed when the administration occurred before the endodontic procedure. When it was administered after the procedure, adverse reactions were reported in 2 of 3 trials included in the analysis.

Limitations: A restricted number of randomised clinical trials were found, and the difference in the methodology of the studies did not meet the definition of a systemic treatment protocol for prevention or control of postoperative pain.

Conclusion:

Nonsteroidal anti-inflammatory drugs are the most common medicament to prevent and control postoperative pain, with ibuprofen being the most investigated. There is a significant association between the use of additional analgesics and periapical diagnoses.

Effect of intracanal cryotherapy on postendodontic pain: a systematic review and meta-analysis of randomized controlled trials

This systematic review aimed to qualitatively and quantitatively evaluate the effectiveness of cryotherapy in the reduction of postendodontic pain. The review question was, "What will be the success rate of cryotherapy technique among human patients with postendodontic pain?". The review protocol was framed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Six studies were included in the review, and quantification of five studies was performed through a meta-analysis. In the forest plot representation of the studies comparing the control and cryotherapy groups in terms of the success rate in the management of postendodontic pain, the combined risk ratio (RR) was 0.80 (95% CI: 0.56 to 1.13) with a P value of 0.20. Based on the quantitative analysis, it can be suggested that intracanal cryotherapy does not play a significant role in reducing postendodontic pain.

Postoperative Pain After the use of Sodium Hypochlorite gel and Solution Forms: A Randomized Clinical Study

OBJECTIVE

The present study aimed to compare the effect of sodium hypochlorite (NaOCl) gel and solution forms on postoperative pain level.

METHODS

Fifty-two patients were divided into two groups according to the root canal irrigation solution. In the NaOCl solution group, the root canals were irrigated with 2 mL of 5.25% NaOCl between each pecking motion. In the NaOCl gel group, 5.25% NaOCl gel was used according to the manufacturer's instructions. The root canal treatments were completed and the participants were given instructions to record postoperative pain levels on 24, 48, and 72 hours and 1 week after treatment using VAS.

RESULTS

Intergroup analyses revealed that the NaOCl gel group resulted in significantly less postoperative pain than the NaOCl solution group on day 1.

CONCLUSION

It can be concluded that using NaOCl gel during root canal preparation results in less postoperative on day 1 when compared with the NaOCl solution.

Evaluation of postoperative pain/discomfort after intracanal use of Nd:YAG and diode lasers in patients with symptomatic irreversible pulpitis and asymptomatic necrotic pulps: a randomized control trial

OBJECTIVES

This study aimed to investigate the ability of the diode and Nd:YAG lasers to decrease postoperative pain/discomfort after intracanal application in vital and devital endodontic cases.

MATERIAL AND METHODS

One hundred two patients with symptomatic irreversible pulpitis and asymptomatic necrotic pulps were selected and randomly divided into three groups. After chemomechanical preparation, Nd:YAG and diode laser was applied to first and second groups for final treatment of the root canals. In the control group, no further disinfection protocol was performed upon traditional procedures. Then all the teeth were obturated in the same appointment. Pre- and postoperative pain were recorded using the VAS at 0, 12th, 24th, 48th, and 72nd hours following the treatment Kruskal-Wallis and Dunn test.

RESULTS

VAS scores were significantly the most at 12-h period compared with other time periods after treatment for all groups. There was no significant difference among Nd:YAG laser, diode laser, and control groups in non-vital cases (p > 0.05). In vital cases, Nd:YAG laser group represented significantly fewer scores compared with diode laser and control groups at 48-h period (p < 0.05).

CONCLUSIONS

The processes involving the use of Nd:YAG and diode lasers after chemomechanical preparation was found to be equivalent in terms of postoperative pain intensity after completion of treatment in one session both in vital or non-vital cases except in vital cases in Nd:YAG group at 48 h.

CLINICAL RELEVANCE

Adjunct clinical use of Nd:YAG or diode lasers to traditional chemomechanical preparation did not cause any improvement or deterioration on postoperative discomfort and pain in patients with symptomatic irreversible pulpitis and asymptomatic necrotic pulps.

Effectiveness of Intracanal Cryotherapy in Root Canal Therapy: A Systematic Review and Meta-analysis of Randomized Clinical Trials

INTRODUCTION

The effectiveness of intracanal cryotherapy for reducing postoperative pain is unclear. The objective of this systematic review was to evaluate the effect of intracanal cryotherapy on postoperative pain after root canal therapy in patients with pulpal or periradicular pathosis.

METHODS

We searched PubMed, Embase, Scopus, and the Cochrane Library as well as the top 3 endodontic journals for relevant articles. We included randomized controlled trials that included adults. Our main outcome was postoperative pain intensity measured with a validated scale. We assessed the risk of bias using the Cochrane criteria and the quality of the included studies using Grading of Recommendation Assessment, Development, and Evaluation. We used a random-effects model for meta-analysis.

RESULTS

Eight studies involving 810 patients were included. The overall risk of bias was moderate. Seven of 8 studies used a visual analog scale to measure pain intensity. Compared with controls, intracanal cryotherapy significantly reduced postoperative pain at 6 (mean difference = -1.37; 95% confidence interval [CI], -0.61 to -2.14; P < .05; I2 = 76%; moderate-quality evidence) and 24 hours after the procedure (mean difference = -1.43; 95% confidence interval, -0.70 to -2.15; P < .05; I2 = 89%; moderate-quality evidence). There was no significant effect on pain at 48 and 72 hours and 7 days after the procedure.

CONCLUSIONS

Moderate-quality evidence suggests that intracanal cryotherapy (ie, using cold saline irrigation as a final irrigant) significantly reduces the intensity of pain at 6 and 24 hours after root canal therapy. Future clinical trials assessing the effectiveness of intracanal cryotherapy are advocated.

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.

Determination of Anesthetic Efficacy of Lidocaine Versus Bupivacaine in Single Visit Root Canal Treatment

Objective:

To compare the anesthetic efficacy of 2% Lidocaine with 1:80,000 epinephrine and 0.5% Bupivacaine with 1:200,000 epinephrine in one-visit root canal treatment in patients with symptomatic irreversible pulpitis.

Methods:

A total of 60 patients presenting with symptomatic irreversible pulpitis with normal periapical tissues on periapical radiography of mandibular 1^st and 2^nd molars, reporting moderate to severe pain as assessed by visual analogue scale (VAS) for at least 24 hours were included in this study. All patients received local anesthesia via the inferior alveolar nerve block technique by the investigator. These patients were randomly allocated into two groups in which first group received 2% lidocaine with 1:80,000 epinephrine and the second group received 0.5% bupivacaine with 1:200,000 epinephrine. Patients were instructed to rate the intensity of pain during root canal treatment which was then noted on visual analogue scale (VAS).

Results:

The average age of the patients was 34.15±9.49 years, in which 32 (53.3%) were male and 28 (46.7%) were female. The anesthetic efficacy was significantly high in bupivacaine as compared to lidocaine local anesthesia group (76.7% versus 40%; P=0.004).

Conclusion:

The administration of bupivacaine anesthetic agent for inferior alveolar nerve block (IANB) injections can be a better and appropriate pain management aid as compared to lidocaine during root canal treatment of patient with symptomatic irreversible pulpitis.

Effect of Diclofenac Potassium Premedication on Postendodontic Pain in Mandibular Molars with Symptomatic Irreversible Pulpitis: A Randomized Placebo-Controlled Double-Blind Trial

INTRODUCTION

The aim of this prospective, randomized, double-blind clinical trial was to evaluate the effect of a preoperative, single, oral dose of diclofenac potassium (DFK) on postoperative pain and rescue analgesic intake in patients with symptomatic irreversible pulpitis in mandibular molars treated in 1 visit.

METHODS

Seventy emergency patients with moderate to severe preoperative pain randomly received either 50 mg DFK or placebo tablets 1 hour before starting endodontic treatment (n = 35 per group). Patients recorded their pain level 6, 12, 24, and 48 hours after treatment on a 170-mm Heft-Parker visual analog scale. The incidence of rescue analgesic intake was also recorded. Outcome data were statistically analyzed using Mann-Whitney U, Friedman, Wilcoxon signed rank, and chi-square tests. Binary logistic regression assessed the association of predisposing factors with postoperative pain. The significance level (α) was set at 0.05.

RESULTS

Of the 70 patients, 68 were analyzed (n = 34 per group). Both groups had similar baseline characteristics (P > .05). DFK showed significantly less pain incidence and intensity than the placebo at 48 hours only (P < .05). A significant decrease occurred from 24 to 48 hours with DFK (P < .05), which was not recorded with the placebo (P > .05). No difference in the incidence of rescue analgesic intake was reported between groups (P > .05). Food intake timing, sex, and rescue analgesic intake were associated with postoperative pain (P < .05).

CONCLUSIONS

Premedication by a single, oral dose of 50 mg DFK could be effective in reducing postendodontic pain at 48 hours after 1-visit endodontic treatment in mandibular molars with symptomatic irreversible pulpitis.

Pre-operative ketorolac efficacy with different anesthetics, irrigants during single visit root canal treatment of mandibular molars with acute irreversible pulpitis

Mandibular molar teeth with acute irreversible pulpitis pose challenges in single visit root canal treatment - (i) success of local anaesthesia and (ii) post-operative pain. One hundred and twenty-six patients with pain associated with carious mandibular molar teeth were enrolled. All patients were administered 10 mg of ketorolac tromethamine prior to local anaesthesia. Local anesthetics used were 2% lignocaine with 1:80 000 adrenaline and 4% articaine with 1:100 000 adrenaline. Three irrigation solutions were used - saline, 3% sodium hypochlorite and dexamethasone. Mean intra-operative pain scores for the lignocaine and articaine groups were 4.33 (±2.58) and 4.22 (±2.88), respectively. There was a statistically significant difference (P = 0.000) in post-operative pain incidence between the lignocaine and articaine groups with 16.7% (10 patients) and 49.2% (29 patients), respectively. Pre-operative ketorolac tromethamine was not effective in reducing the intra-operative pain incidence. However, it was effective in controlling post-operative pain with lignocaine anesthetic group.

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.

Postoperative Quality of Life Following Conventional Endodontic Intracanal Irrigation Compared with Laser-Activated Irrigation: A Randomized Clinical Study

Objective: The aim of this randomized clinical study was to evaluate the effect of laser-activated irrigation using a photon-induced photoacoustic streaming (PIPS) technique on postoperative pain following completion of root canal obturation. Methods: Fifty-six patients were enrolled in this randomized clinical trial. Fifty-six healthy premolars or molars with asymptomatic irreversible pulpitis, symptomatic irreversible pulpitis, or symptomatic pulpal necrosis, with or without apical periodontitis, were mechanically prepared for endodontic treatment and divided into two groups. Patients were randomly allocated to treatment groups. In the positive control group G1, the final irrigation with 2 cc of 5.25% sodium hypochlorite (NaOCl) was achieved using a 27G needle, introduced into the canal to a distance of 5 mm from the predetermined working length. In the experimental group G2, the root canals were irrigated with 17% ethyldiamine tetric acid (EDTA) and 5.25% NaOCl following the PIPS protocol, using an Er:YAG 2940 nm laser (LightWalker ATS^®; Fotona, Slovenia) with a 600 μm diameter tip and operating parameters of 20 mJ per pulse, 15 Hz frequency, 0.3 W average power, and a 50-μs pulse duration. Postoperatively, the patients were advised to take a minor analgesic (ibuprofen 400 mg) in the event of pain perception. Postoperative pain levels were assessed after 24, 48, and 72 h and 7 days through the use of a Visual Analogue Scale questionnaire, completed by each patient. Data were analyzed using Kolmogorov-Smirnov, Fisher Exact, Chi square, Mann-Whitney test, and Friedman's test. The level of significance was set at α = 0.05. Results: There was no significant difference between the laser-irradiated group and the control group (p < 0.5). Laser activation of irrigating solutions did not increase postoperative pain. Conclusions: The outcome of this investigation indicated that PIPS was as effective as conventional irrigation in relation to postoperative pain, making this activation technique interesting to use for supplementary root canal disinfection.

Influence of anti-inflammatory irrigant on substance P expression for single-visit root canal treatment of teeth with irreversible pulpitis

One of the main objectives of root canal treatment is to alleviate the pain associated with irreversibly inflamed pulps. However, some patients may have moderate to severe pain following treatment. The aim of this study was to compare and assess the effect of ketorolac tromethamine on substance P expression in the pulp and periapical tissues when used as a root canal irrigant for single-visit root canal treatment in teeth with irreversible pulpitis. Thirty-six patients were randomly allotted to three irrigant groups - saline (n = 14), 3% sodium hypochlorite (n = 11) and ketorolac tromethamine (n = 11). Pulp blood samples (S1) were collected on gaining access to the pulp, and periapical blood samples (S2) were collected after root canal preparation. Quantification of substance P was done by ELISA test. The ketorolac tromethamine group had greater reduction in substance P expression (S2). Post-operative pain levels were not significantly influenced by the different root canal irrigants.

The Effect of Submucosal Injection of Corticosteroids on Pain Perception and Quality of Life after Root Canal Treatment of Teeth with Irreversible Pulpitis: A Randomized Clinical Trial

INTRODUCTION

The aim of the present investigation was to study the effect of local infiltration of corticosteroids on postoperative pain and quality of life (QOL) in teeth with irreversible pulpitis after 1-visit endodontic treatment.

METHODS

In this double-blind randomized clinical trial, 242 healthy patients with irreversible pulpitis undergoing 1-visit endodontic treatment were included. Forty-five patients were lost during the follow-up, and the remaining 197 patients were followed for 7 days (67 patients in the placebo group, 66 in the long-acting betamethasone group, and 64 in the dexamethasone group). The patients marked their level of pain and QOL before treatment and at 6-, 12-, 24-, 48-, and 72-hour and 7-day postoperative intervals using a questionnaire. Freidman and Kruskal-Wallis tests were used for statistical analysis. P ≤ .05 was considered significant.

RESULTS

The pain was more severe in the placebo group compared with the other groups at all time intervals. A significant increase was observed in pain severity after 12 hours in all 3 groups. In general, the pain was less severe in the dexamethasone group compared with the betamethasone group at 6-, 12-, and 24-hour intervals. The pain severity was similar in both groups at 48 hours, and it was less severe in the long-acting betamethasone group compared with the dexamethasone group after 72 hours and 7 days. There were no significant differences in the betamethasone and dexamethasone groups in pain intensity between males and females. Moreover, overall pain perception was higher in the mandible than in the maxilla. There was an inverse and significant relationship between pain severity and QOL.

CONCLUSIONS

Infiltration of long-acting betamethasone and dexamethasone resulted in decreased postoperative pain experience. Dexamethasone was more effective in alleviating pain within the first 24-hour period after treatment. Infiltration of long-acting betamethasone and dexamethasone exhibited the same efficacy in 48 hours. The efficacy of long-acting betamethasone in pain relief lasted for 7 days. The QOL in the 2 groups receiving corticosteroids was higher than that in the placebo group.

Comparison of postoperative pain intensity after using reciprocating and continuous rotary glide path systems: a randomized clinical trial

Objectives

The aim of this study was to compare postoperative pain intensity after root canal treatment with One G (OG) vs. R-Pilot (RP) files used for glide path preparation.

Materials and Methods

Ninety-three single-canaled mandibular premolar teeth with asymptomatic non-vital pulp were randomly assigned into 3 groups (n = 31): OG, RP, or without glide path (WGP). After creating the glide path, the root canals were prepared using sequential Mtwo rotary files to size 30/0.05. One endodontic specialist carried out single-visit endodontic treatment. The patients were asked to rate the severity of postoperative pain on a visual analogue scale at 24, 48, and 72 hours after the visit. They were also asked to record their intake of prescribed analgesics taken. The data were analyzed using the χ², Friedman, Kruskal-Wallis, and Mann-Whitney U tests.

Results

In all 3 groups, postoperative pain decreased significantly at each time interval (p < 0.05). At 24 hours, the OG group had less postoperative pain than the WGP group (p < 0.05). However, no significant difference was found between the RP group and the others. No statistically significant difference was found among the WGP, OG, and RP groups in postoperative pain intensity at 48 or 72 hours or in analgesic tablet intake at the 3 assessed time intervals.

Conclusions

The OG group had less postoperative pain than the WGP group in the first 24 hours. The OG and RP systems were similar regarding postoperative pain intensity and analgesic intake.

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.

Effects of Ibuprofen Compared to Other Premedication Drugs on the Risk and Intensity of Postendodontic Pain: A Systematic Review

Objective

This systematic review aims to evaluate the effects of ibuprofen compared to other drugs on the risk and intensity of postoperative pain resulting from endodontic treatment in adult patients.

Methods

A systematic search was carried out through Medline databases (Pubmed, Scopus, Web of Science, Cochrane, Lilacs, and BBO). There was no restriction on the publication year or idiom. The gray literature was explored. The Periodicos Capes Theses Databases and ProQuest Dissertations were also searched, as well as the unpublished and ongoing trials registry and the IADR abstracts (1990-2016). Solely randomized clinical trials that compared the risk or intensity of pain resulting from endodontic treatment in adult patients were included in this systematic review. The risk of bias of the articles was evaluated using the Cochrane Collaboration's tool. A random-effect meta-analysis was conducted for ibuprofen versus placebo and ibuprofen versus other drugs at 6, 8, and 24 hours. The GRADE approach was used to assess the quality of the evidence.

Results

A total of 1132 studies were identified, and only seven meet the eligibility criteria. No difference between the groups was detected in any of the meta-analysis. An exception was observed when one study was removed from the meta-analysis of pain intensity at 24 hours for ibuprofen versus placebo, favoring ibuprofen (SMD -0.67; 95% CI -1.05 to -0.17). The quality of evidence in all meta-analyses was graded as low or very low.

Conclusion

Results of the present systematic review indicate that there is no clear evidence supporting that preoperative ibuprofen is better than other drugs in reducing the risk and intensity of postendodontic pain.

Effects of Various Cryotherapy Applications on Postoperative Pain in Molar Teeth with Symptomatic Apical Periodontitis: A Preliminary Randomized Prospective Clinical Trial

INTRODUCTION

The purpose of the study was to evaluate the effects of intracanal, intraoral, and extraoral cryotherapy on postoperative pain in molar teeth with symptomatic apical periodontitis.

METHODS

A total of 100 patients were randomly distributed into 4 groups: control (without cryotherapy application), intracanal cryotherapy application, intraoral cryotherapy application, and extraoral cryotherapy application. The postoperative pain of the patients was recorded at the first, third, fifth, and seventh days. The data were statistically analyzed by using linear regression, χ², one-way analysis of variance, Tukey post hoc, and Kruskal-Wallis H tests (P = .05).

RESULTS

There were no statistically significant differences among the groups in terms of demographic data (P > .05). The preoperative pain levels and preoperative visual analogue scale (VAS) scores of pain on percussion were similar among the groups (P > .05). The linear regression analysis demonstrated that group variable had the most significant effect on postoperative pain at day 1 (P < .001) among the other variables (group, age, gender, tooth number, preoperative pain levels, and VAS scores of pain on percussion). When compared with the control group, all the cryotherapy groups exhibited less percussion pain and less postoperative pain at the first, third, fifth, and seventh days (P < .05).

CONCLUSIONS

Within the study limitations, all the cryotherapy applications (intracanal, intraoral, and extraoral) resulted in lower postoperative pain levels and lower VAS scores of pain on percussion versus those of the control group.

Comparative evaluation of the efficacy of diclofenac sodium administered using different delivery routes in the management of endodontic pain: A randomized controlled clinical trial

Introduction

Pain of endodontic origin is of concern to both the patient and the clinician. Expectation of a painful experience can increase the patient's anxiety levels, making treatment more difficult. Management of endodontic pain is one of the challenging aspects in endodontics.

Objective

To evaluate whether the intraligamentary mode of administration of diclogfenac sodium is effective in abating endodontic pain during interappointment visits.

Aim

The purpose of this clinical trial is to evaluate the analgesic efficacy of diclofenac sodium administered through oral and intraligamentary routes in reducing postendodontic pain.

Materials and Methods

Thirty patients were randomly allocated into three groups. Group A - placebo (Vitamin B12), Group B - diclofenac sodium (intraligamentary), and Group C - diclofenac sodium tablets. The tablets were given 30 min before the start of the procedure, while the intraligamentary injection was administered before commencing the endodontic procedure. The visual analog scale was used to evaluate the pain score at baseline and 6, 12, 24, and 48 h postoperatively.

Results

Prophylactic intraligamentary injection of diclofenac sodium was found to be highly effective in reducing postendodontic pain than the oral route of administration.

Conclusion

In patients with low pain threshold, intraligamentary route of administration is effective in controlling pain of endodontic origin postoperatively.

Comparison of two combinations of opioid and non-opioid analgesics for acute periradicular abscess: a randomized clinical trial

Acute periradicular abscess is a condition characterized by the formation and propagation of pus in the periapical tissues and generally associated with debilitating pain.

Comparison of Acupuncture with Ibuprofen for Pain Management in Patients with Symptomatic Irreversible Pulpitis: A Randomized Double-Blind Clinical Trial

Emergency pain management in symptomatic irreversible pulpitis commonly includes use of nonnarcotic analgesics. Acupuncture has been used in dentistry to alleviate pain after tooth extraction. The aim of this randomized, double-blind, placebo controlled clinical trial was to evaluate and compare the efficacy of acupuncture therapy and ibuprofen for pain management in such patients. A total of 157 patients participated in this study and were randomly assigned to three groups, Group I-classical acupuncture with placebo tablet, Group II-sham acupuncture with placebo tablet, and Group III-sham acupuncture with ibuprofen. Before commencement of the experiment, initial pain assessment was done using a HP-VAS scale. Treatment was done by first operator, while pain assessment was done by the second operator who was blinded to the procedure performed. Acupuncture needles were inserted for 15-20 minutes at acupoints for classical acupuncture and at nonacupoints for sham acupuncture. Posttreatment pain assessment was carried out at 15, 30, 45, and 60 minutes intervals. Follow-up analysis was recorded at 12, 24, and 48 hours using VAS verbal scale. The mean final HP VAS values for Group I showed statistically significant lower pain values when compared with groups II and III (p < 0.05), with no significant difference between groups II and III. Follow-up analysis showed Group I with higher percentage of no pain, which was statistically significant when compared with other two groups. It can be concluded that classical acupuncture is more effective in pain relief (faster and prolonged) than analgesics.

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%.

Predictors, prevention, and management of postoperative pain associated with nonsurgical root canal treatment: A systematic review

Postoperative pain after root canal treatment can be reduced by applying recent advances in endodontic techniques and equipment. This systematic review includes current knowledge about pain after nonsurgical root canal treatment, including predictors, related factors, effects of recent advances, and management. A literature search was performed using the PubMed, ScienceDirect, and Cochrane Library databases for articles published between 1990 and 2016. Search keywords included postoperative pain, nonsurgical treatment, single visit, recent advances in endodontics, and management of postoperative pain with endodontic treatment. Only original research studies were included; editorials, reviews, brief notes, conference proceedings, and letters to the editor were excluded. The initial search yielded 4941 articles, which were assessed and filtered using the selection criteria. Sixty-five studies met the inclusion criteria and were included in the review. The findings showed that pain after nonsurgical root canal treatment occurred in 3–69.3% of patients. Microorganisms were identified as the primary contributors to postoperative pain, and there was no significant difference in postoperative pain between single- and multiple-visit treatments. Postoperative pain after root canal treatment ranges from mild to moderate and occurs even after optimally performed procedures. Furthermore, adequate management of postoperative pain is often considered an indicator of clinical excellence. Application of recently developed endodontic techniques and devices will reduce postoperative pain. Furthermore, a flexible, severity-based drug administration plan can be used to control and manage pain after root canal treatment. Application of the current research findings will reduce pain following root canal treatment and improve patient outcomes.

Comparative assessment of efficacy of two different pretreatment single oral doses of betamethasone on inter-appointment and postoperative discomfort: An in vivo clinical evaluation

Aim:

Study aimed to evaluate the efficacy of two different pretreatment single oral doses of betamethasone on the incidence of inter-appointment flare up and postoperative discomfort.

Materials and Methods:

Fifty-four patients aged 18–59 years requiring endodontic treatment were selected and randomly assigned to three groups; single pretreatment oral dose of placebo or betamethasone in two different oral doses of 0.5 mg and 1 mg, respectively. Endodontic therapy was completed in two visits using triple antibiotic paste as intracanal medicament. Patients were given a questionnaire to record their pain at 1, 2, 3, and 7 days after treatment. In the second visit, obturation was done, and the patients were again instructed to record their pain scores after treatment and discharged. The verbal rating scale was used for recording the pain scores. Statistical analysis was done using ANOVA and the Friedman test.

Results:

0.5 mg betamethasone group showed least mean pain scores among all experimental groups; however, there was no statistically significant difference between any of the groups (P > 0.05).

Conclusion:

Pretreatment single oral dose of betamethasone is an effective in managing endodontic flare-ups; however, the results were statistically insignificant.

Multiple-file vs. single-file endodontics in dental practice: a study in routine care

BACKGROUND

Little is known about the differences of rotary multiple file endodontic therapy and single-file reciprocating endodontic treatment under routine care conditions in dental practice. This multicenter study was performed to compare the outcome of multiple-file (MF) and single-file (SF) systems for primary root canal treatment under conditions of general dental practice regarding reduction of pain with a visual analogue scale (VAS 100), improvement of oral-health-related quality of life (OHRQoL) with the german short version of the oral health impact profile (OHIP-G-14) and the speed of root canal preparation.

MATERIALS AND METHODS

Ten general dental practitioners (GDPs) participated in the study as practitioner-investigators (PI). In the first five-month period of the study, the GDPs treated patients with MF systems. After that, the GDPs treated the patients in the second five-month period with a SF system (WaveOne). The GDPs documented the clinical findings at the beginning and on completion of treatment. The patients documented their pain and OHRQoL before the beginning and before completion of treatment.

RESULTS

A total of 599 patients were included in the evaluation. 280 patients were in the MF group, 319 were in the SF WaveOne group. In terms of pain reduction and improvement in OHIP-G-14, the improvement in both study groups (MF and SF) was very similar based on univariate analysis methods. Pain reduction was 34.4 (SD 33.7) VAS (MF) vs. 35.0 (SD 35.4) VAS (SF) (p = 0.840) and the improvement in OHIP-G-14 score was 9.4 (SD 10.3) (MF) vs. 8.5 (SD 10.2) (SF) (p = 0.365). The treatment time per root canal was 238.9 s (SD 206.2 s) (MF) vs. 146.8 sec. (SD 452.8 sec) (SF) (p = 0.003).

DISCUSSION

Regarding improvement of endodontic pain and OHRQoL measure with OHIP-G-14, there were no statistical significant differences between the SF und the MF systems. WaveOne-prepared root canals significantly faster than MF systems.

Nonsteroidal Anti-inflammatory Drugs for Managing Postoperative Endodontic Pain in Patients Who Present with Preoperative Pain: A Systematic Review and Meta-analysis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been commonly used to treat endodontic postoperative pain. The purpose of this study was to address the following Population, Intervention, Comparator, Outcome, Timing, Study design and setting question: in patients with preoperative pain who undergo initial orthograde endodontic treatment, what is the comparative efficacy of NSAIDS compared with non-narcotic analgesics or placebo in reducing postoperative pain and the incidence of adverse events.

METHODS

Ovid MEDLINE (1946-December 15, 2015), the Cochrane Database of Systematic Reviews (2005-December 15, 2015), and the Cochrane Central Register of Controlled Trials (to December 15, 2015) were searched using included drugs, indications, and study designs as search terms. Hand searches in texts were also conducted. Two independent reviewers assessed eligibility for inclusion, extracted data, and assessed quality using the risk of bias tool. L'Abbe plots were used for qualitative review. Where applicable, meta-analysis was conducted on the pooled effect size (ES).

RESULTS

Two thousand two hundred eighty-four studies were identified through the database searches; 405 full-text articles were assessed. Fifteen articles met the inclusion criteria; qualitative analysis revealed all studies had a moderate to high risk of bias. Ibuprofen was the most studied NSAID. The L'Abbe plots showed that NSAIDS are effective at relieving postoperative endodontic pain overall. Meta-analysis showed that ibuprofen 600 mg is more effective than placebo at 6 hours postoperatively (ES = 10.50, P = .037), and ibuprofen 600 mg + acetaminophen 1000 mg combination is more effective than placebo (ES = 34.89, P = .000) but not significantly different than ibuprofen (ES = 13.94, P = .317). Five studies reported patients experiencing adverse events such as drowsiness, dizziness, nausea, and emesis; 2 studies reported that patients experienced no adverse events.

CONCLUSIONS

A combination of ibuprofen 600 mg and acetaminophen 1000 mg is more effective than placebo but not significantly different than ibuprofen 600 mg at 6 hours postoperatively. Ibuprofen 600 mg is more effective than placebo at 6 hours postoperatively; however, there are insufficient data to recommend the most effective NSAID, dose amount, or dose interval for the relief of postoperative endodontic pain of longer duration in patients with preoperative pain.