Effect of Ibuprofen on Masking Endodontic Diagnosis

Assessment of mechanical allodynia in healthy teeth adjacent and contralateral to endodontically diseased teeth: a clinical study

Objectives

The present study investigated the prevalence of mechanical allodynia (MA) in healthy teeth adjacent and contralateral to endodontically diseased teeth.

Materials and Methods

This cross-sectional study included 114 patients with symptomatic irreversible pulpitis and apical periodontitis in permanent mandibular first molars who possessed healthy teeth adjacent and contralateral to the endodontically diseased tooth. The mechanical sensitivity of the teeth was determined by percussion testing. The presence or absence of pain on percussion in the teeth adjacent and contralateral to the endodontically diseased tooth and the tooth distal to the contralateral symmetrical tooth was recorded according to coding criteria. The prevalence of MA was computed as a percentage, and binary logistic regression analysis was done. The Fisher exact test and Mann-Whitney U test were used for binary and ordinal data.

Results

Age and sex did not influence the prevalence of MA. An increased prevalence of MA was found in patients with higher levels of spontaneous pain (p < 0.001). The prevalence of allodynia was 57% in teeth adjacent to endodontically diseased teeth and 10.5% in teeth contralateral to endodontically diseased teeth. In addition, on the ipsilateral side, there were more painful sensations distal to the diseased tooth than mesially.

Conclusions

Despite being disease-free, teeth adjacent and contralateral to endodontically diseased teeth exhibited pain on percussion. There was a direct association between the severity of the patient's pain and the presence of MA.

Cannabidiol as an Alternative Analgesic for Acute Dental Pain

Odontogenic pain can be debilitating, and nonopioid analgesic options are limited. This randomized placebo-controlled clinical trial aimed to assess the effectiveness and safety of cannabidiol (CBD) as an analgesic for patients with emergency acute dental pain. Sixty-one patients with moderate to severe toothache were randomized into 3 groups: CBD10 (CBD 10 mg/kg), CBD20 (CBD 20 mg/kg), and placebo. We administered a single dose of respective oral solution and monitored the subjects for 3 h. The primary outcome measure was the numerical pain differences using a visual analog scale (VAS) from baseline within and among the groups. Secondary outcome measures included ordinal pain intensity differences, the onset of significant pain relief, maximum pain relief, changes in bite force within and among the groups, psychoactive effects, mood changes, and other adverse events. Both CBD groups resulted in significant VAS pain reduction compared to their baseline and the placebo group, with a maximum median VAS pain reduction of 73% from baseline pain at the 180-min time point (P < 0.05). CBD20 experienced a faster onset of significant pain relief than CBD10 (15 versus 30 min after drug administration), and both groups reached maximum pain relief at 180-min. Number needed to treat was 3.1 for CBD10 and 2.4 for CBD20. Intragroup comparisons showed a significant increase in bite forces in both CBD groups (P < 0.05) but not in the placebo group (P > 0.05). CBD20 resulted in a significant difference in mean percent bite force change in the 90- and 180-min time points compared to the placebo group (P < 0.05). Compared to placebo, sedation, diarrhea, and abdominal pain were significantly associated with the CBD groups (P < 0.05). There were no other significant psychoactive or mood change effects. This randomized trial provides the first clinical evidence that oral CBD can be an effective and safe analgesic for dental pain.

Assessment of Preferences in Taking Painkillers among Students of Medicine, Dentistry, and Pharmacy: A Pilot Study

Students of pharmacy, medicine, and dentistry are important for shaping drug policy. The aim of this study is to assess and compare students preferences in taking painkillers. The study group consists of 382 students of pharmacy (28.8%), medicine (40.0%), and dentistry (30.1%). An anonymous questionnaire consisting of 17 questions was prepared using the Google Forms platform and distributed through social media. Ibuprofen was the most frequently preferred, regardless of the study major (57.8%). Pharmacy students expressed the least concern about the possible side effects of analgesics (17.5%). The fast onset of painkillers was more important for dental students (59.1%) and pharmacy students (44.7%), compared to medical students (39.22%). Medicine and pharmacy students indicated their studies to be their main source of information about painkillers compared to dentistry students (p = 0.001). There are no differences in pain severity regarding which analgesics are used among student groups (p = 0.547). Dental students experienced odontogenic pain less frequently (57.3%) than medical (79.7%) and pharmacy students (79.8%), (p = 0.000). Ketoprofen was the most frequently chosen prescription painkiller for odontogenic pain in all groups (49.4%). Gastrointestinal complaints were the most often reported side effects, regardless of the study major (87.1%). Choice of studies, gender, and year of study were the most important determinants of the choice of painkillers.

Microbiome in paired root apices and periapical lesions and its association with clinical signs in persistent apical periodontitis using next-generation sequencing

AIM

To assess and compare the microbiome of paired root apices and periapical lesions from cases with failed endodontic treatment and to associate the microbiome and bacterial metabolic pathways in both sites with asymptomatic apical periodontitis (AAP) and symptomatic apical periodontitis (SAP), using next-generation sequencing (NGS).

METHODOLOGY

Matched root apices and periapical lesions of patients with failed root canal treatments were surgically extracted. Specimens were cryopulverized, bacterial DNA was extracted and the V3-V4 hypervariable regions of the 16 S rRNA gene were amplified and sequenced using the Illumina Miseq platform. Diversity and community composition were studied in the paired samples, as well as in AAP and SAP cases. Diversity indices were compared in each case by means of the Wilcoxon matched-pairs signed rank and Mann-Whitney U tests. Differences in the community composition were explored with multivariate statistical analysis and Linear discriminant analysis Effect Size (LEfSe). Bacterial functional study was performed through the Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) analysis.

RESULTS

Twenty-one paired apices and lesions were successfully sequenced and analysed, identifying a total of 21 phyla and 600 genera. A higher alpha-diversity was observed in the periapical lesions, although no global differences in the community composition between the two sites were found (p = .87), the most prevalent genera being Fusobacterium, Porphyromonas and Streptococcus. Prevotella, Clostridiales_vadinBB60_group, Bosea, Phreatobacter, Afipia and Xanthobacteriaceae_unclassified were enriched in SAP samples, while Pseudopropionibacterium, Campylobacter and Peptoniphilus were significantly more abundant in AAP cases (p < .05). Metabolic pathways involved in the amino acid metabolism or degradation and flagellum assembly were more abundant in SAP samples, whereas glucose metabolism-related pathways were associated with AAP.

CONCLUSIONS

The bacterial community composition was similar in the apices and periapical lesions. The microbiome was different in AAP and SAP samples, gram-negative bacteria showing higher relative abundances in SAP cases. An association was observed between amino acid degradation and flagellum assembly pathways, and the development of tenderness to percussion or palpation.

Evaluation of the Effect of Common Analgesics on Pulpal Sensibility Tests: A Clinical Trial

INTRODUCTION

Accurate diagnosis is one of the most important steps before endodontic treatment. The aim of this study was to assess the effect of 2 commonly used analgesics namely ibuprofen and acetaminophen on the cold and electric pulp test (EPT) results in participants with symptomatic irreversible pulpitis (SIP).

METHODS

This clinical trial evaluated 41 participants with pain due to SIP. The cold test and EPT were performed for teeth with SIP, and also for the corresponding tooth with healthy pulp in the contralateral quadrant. The participants then received 500 mg acetaminophen, 400 mg ibuprofen, or the placebo in the 3 groups. The cold test and EPT were repeated at 20, 40, and 60 minutes after medication intake, and the results were compared with the pretreatment values.

RESULTS

In the acetaminophen group, the results of cold test significantly decreased 40 (P < .05), and 60 (P < .05) minutes after analgesic intake in teeth with SIP and after 40 minutes (P < .05) in the corresponding contralateral teeth with healthy pulp. In the ibuprofen group, the cold test results significantly decreased at 20 (P < .05), 40 (P < .05), and 60 (P < .05) minutes after analgesic intake in teeth with SIP and after 40 minutes (P < .05) in the corresponding contralateral teeth with healthy pulp. The EPT results were not significantly affected by the studied analgesics at any time point (P > .05). There was no significant difference among the study groups regarding sex (P > .05).

CONCLUSION

It appears that both acetaminophen and ibuprofen can affect the pulpal response to the cold sensibility test. However, the studied medications had no significant effect on the EPT results. Therefore, dental clinicians should be aware of the possible effects of such medications on the cold test response.

Is tele-diagnosis of dental conditions reliable during COVID-19 pandemic? Agreement between tentative diagnosis via synchronous audioconferencing and definitive clinical diagnosis

Objectives

To assess the reliability of synchronous audioconferencing teledentistry (TD) in making tentative diagnosis compared to definitive clinical face-to-face (CFTF) diagnosis; and whether agreement was influenced by dentist's experience, caller-patient relationship, and time of call.

Methods

All patients calling the TD hotline during COVID-19 pandemic, triaged as emergency/ urgent and referred for CFTF care were included (N=191). Hotline dentists triaged the calls, made tentative audio-dentistry (AD) diagnosis, while dentists at point of referral made the definitive CFTF diagnosis. Cohen's weighted kappa (κ) assessed the extent of agreement between AD vs CFTF diagnosis.

Results

There was significantly very good pair-wise agreement (κ = 0.853, P < 0.0001) between AD and CFTF diagnosis. AD diagnosis of pulpitis and periodontitis exhibited the most frequent disagreements. Tele-dentists with ≥ 20 years’ experience exhibited the highest level of agreement (κ =0.872, P < 0.0001). There was perfect agreement when mothers mediated the call (κ = 1, P < 0.0001), and very good agreement for calls received between 7 am-2 pm (κ = 0.880, P < 0.0001) compared to calls received between 2-10 pm (κ = 0.793, P < 0.0001).

Conclusions

Remote tentative diagnosis using AD is safe and reliable. Reliability was generally very good but varied by dentist's experience, caller-patient relationship, and time of call.

Clinical significance

The findings suggest that using AD in the home environment is safe and reliable, deploying providers with variable years of experience. The findings have generalizability potential to a variety of similar circumstances, healthcare settings and epi/pandemic situations.

Present status and future directions - Mechanisms and management of local anaesthetic failures

Pain control during root canal treatment is of utmost importance for both the patient and the dental practitioner and many studies have investigated ways of overcoming problems with gaining adequate anaesthesia during treatment. The PubMed and Cochrane databases were searched for evidence-based studies regarding local anaesthesia for root canal treatment. Many variables, including premedication, pain during needle insertion, pain on injection, premedication with various types of drugs, volume of anaesthetic solutions, supplemental anaesthetic techniques, and additives to the anaesthetic solutions, may influence pain perception during root canal treatment. Differences between teeth with healthy pulps versus those with irreversible pulpitis should be considered when the effects of variables are interpreted. There are several concerns regarding the methodologies used in studies that have evaluated anaesthesia success rates. There are some conditions that may help to predict a patient's pain during root canal treatment and these conditions could be overcome either by employing methods such as premedication with a non-steroidal anti-inflammatory drug prior to the treatment visit or by using supplementary anaesthetic techniques before or during the treatment. However, authors need to be more careful when reporting details of their studies to reduce concerns regarding their study bias.

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.

Postoperative pain after ultrasonically and laser-activated irrigation during root canal treatment: a randomized clinical trial

AIM

To compare the intensity of postoperative pain after primary root canal treatment of asymptomatic teeth when using ultrasonically (UAI) or laser-activated irrigation (LAI).

METHODOLOGY

In this superiority randomized clinical trial (ClinicalTrials.gov ID: NCT03981237) with parallel design, fifty-six patients with an asymptomatic tooth in need of primary root canal treatment were enrolled. After chemo-mechanical canal preparation using rotary instruments and NaOCl irrigation, teeth were randomly assigned to two groups and patients were blinded to the final irrigation protocol. In the UAI group (n = 28), 60s activation with an Irrisafe tip was done per canal. In the LAI group (n = 28), NaOCl was activated with a pulsed Er:YAG (2940 nm) laser, equipped with a conical tip, with settings of 50 µs, 20 mJ at 15 Hz for 60 s. Patients recorded their pain intensity 6, 24, 48 and 72 h after treatment on a 100 mm visual analogue scale (VAS), as well as their analgesic consumption. Pain levels and incidence were compared across groups using the Mann-Whitney U-test and chi-square test.

RESULTS

Overall, mean postoperative pain intensity was low, with the majority of patients having no or minimal pain 24 h postoperatively. At 6 h postoperatively, pain intensity and incidence were significantly higher in the UAI group compared to the LAI group (P < 0.05). For the other time intervals, no significant differences in postoperative pain incidence or intensity were found. The frequency of analgesic intake did not differ significantly between the two groups. Neither of the activation methods resulted in any adverse effects.

CONCLUSIONS

Ultrasonically and laser-activated irrigation resulted in low and comparable levels of postoperative pain in asymptomatic patients receiving primary root canal treatment.

Sociodemographic Determinants and Common Reasons for Visiting the Emergency Dental Service in the City of Zagreb

Objective

The objective of the study was to determine the sociodemographic and clinical parameters of patients who visit the emergency dental service and their most common diagnoses.

Materials and Methods

The data were collected on the basis of a survey filled out by patients. A total of 1730 out of 6732 patients (26%) were surveyed using a questionnaire to analyze sociodemographic status, dental visits, the description and dynamics of the symptoms. After the data collection, methods of descriptive data presentation and of inferential statistics were made in SPSS.

Results

Survey results show that most subjects (60.4%) came during the weekends and holidays. The subjects, 73.1% of them, stated that they had already used this type of service, and 65.8% did not visit their dentist beforehand. The largest number of subjects (62.2%) reported that they needed emergency service within a week after their problems had begun. The most common diagnoses included face and jaw abscesses (27.3%). There is a statistically significant difference between the number of patients who went to the emergency dental service and completed the questionnaire over the course of several months contrary to patients who were there in May and June (59.7%) compared to July and August (40.3%).

Conclusions

Most subjects had clear indications for being referred to an emergency dental service. Most of the emergency conditions were mainly due to irregular visits to the dentist. Patient education and preventive programs would probably have reduced the number of visits.

Predicting intraoperative pain in emergency endodontic patients: clinical study

This prospective observational study sought to investigate the incidence of intraoperative pain (IOP) among emergency endodontic patients and to construct an IOP prediction model that includes preoperative pain level (PPL). All patients who underwent emergency endodontic treatment at Gazi University, Ankara, Turkey, during the spring term of 2016 were considered for inclusion in the study. Demographic and clinical variables and PPL were recorded. Local anesthesia was provided to all patients before beginning routine endodontic treatment. IOP was defined as the condition of requiring supplementary anesthesia before the working length was established and exhibiting persistent moderate or severe pain despite supplementary anesthesia. Data from 85% and 15% of 435 patients (178 men, 257 women; mean age: 35 years) were used to develop predictive models by multiple logistic regression analysis and to test external validity of the models, respectively. Two multiple logistic regression models achieved good model fits. Model 1 included age, pulpal diagnosis, and arc (p < 0.05). In addition to these variables, Model 2 included periapical diagnosis and PPL (p < 0.15). Models 1 and 2 showed accuracies of 0.76 and 0.75, sensitivities of 0.74 and 0.77, and specificities of 0.76 and 0.74, respectively for the modeling data (internal validity), and accuracies of 0.82 and 0.80, sensitivities of 0.83 and 0.67, and specificities of 0.81 and 0.81, respectively for the control data (external validity). The IOP incidence was 10.3%. IOP in patients undergoing emergency endodontic treatment can be successfully predicted by using models that account for demographic and clinical variables, including PPL.

A Randomized Clinical Trial Comparing 2 Ibuprofen Formulations in Patients with Acute Odontogenic Pain

INTRODUCTION

Ibuprofen sodium dihydrate, a new formulation of ibuprofen, was introduced with the claim of faster onset of analgesia. Most of the data on this new ibuprofen formulation are drawn from studies using the oral surgery model. Because this model differs significantly from the endodontic pain model, we conducted a study comparing ibuprofen sodium dihydrate with conventional ibuprofen acid in endodontic pain patients.

METHODS

This randomized, double-masked study recruited subjects experiencing moderate to severe pain from a tooth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis (n = 41). Subjects were randomized to receive 400 mg ibuprofen acid (Advil; Pfizer, Madison, NJ) or an equivalent dose of 512 mg ibuprofen sodium dihydrate (Advil Sodium, Pfizer). The outcome measures were time to onset of 50% pain relief recorded using a stopwatch, reduction in spontaneous pain experienced on a 100-mm visual analog scale, and change in mechanical allodynia measured using a bite force transducer. The last 2 measures were obtained before and 60 minutes after administration of the drug.

RESULTS

The median time to onset of 50% pain relief after administration of ibuprofen sodium dihydrate was significantly faster compared with ibuprofen acid (26.5 vs 44 minutes, P = .08). Ibuprofen sodium dihydrate provided a greater reduction in spontaneous pain (50.8% vs 33.3%, P < .05) and mechanical allodynia (15% vs 9%, P > .05).

CONCLUSIONS

In endodontic pain patients, a single dose of ibuprofen sodium dihydrate provides faster onset of pain relief and a greater reduction in spontaneous and evoked pain compared with ibuprofen acid.

Unmasking the Effect of Analgesics on Endodontic Diagnosis Using a Novel Bite Force Sensor Device: A Prospective, Randomized Clinical Trial

INTRODUCTION

A definitive diagnosis is of primary importance before initiating any endodontic treatment; yet, there are occasions when the dental professional is unable to accurately reproduce the patient's chief complaint, as it can pose a dilemma and may require consideration of multiple variables in order to reach an accurate diagnosis. So to overcome this problem, a methodical approach in providing endodontic treatment should be implemented which includes diagnosis, definitive dental treatment and adjunctive drug therapy, known as the "3D" strategy.

AIM

The purpose of this study was to evaluate the possible "masking" effect of these analgesics on endodontic diagnosis using a novel bite force sensor device.

MATERIALS AND METHODS

A total of 90 patients with endodontic pain were selected and they were given either a placebo or 400 mg ibuprofen (brufen) or 50mg diclofenac sodium (voveron). Both patients and operators were completely blinded to the drugs administered. Bite force tolerance values were noted before and one hour after administration of medication using the self designed bite force sensor.

RESULTS

The pre- and post-bite force tolerance values were tabulated for both contralateral and affected tooth. For the affected tooth, there was statistically significant difference between pre- and post-bite force tolerance values in Group I (i.e., ibuprofen) and Group II (i.e., diclofenac sodium) (p<0.05) with no significant difference observed in Group III (placebo).

CONCLUSION

The easily available over the counter self administered analgesics in addition to providing symptomatic relief to patients suffering from symptomatic apical periodontitis may also cloud the definitive diagnosis of the clinician, thus jeopardising the treatment plan. The self designed bite force sensor was effective in arriving at a definitive diagnosis in teeth with chronic irreversible pulpitis with symptomatic apical periodontitis, where the allodynia has been camouflaged by the use of analgesics like ibuprofen and diclofenac sodium.

Pain levels and typical symptoms of acute endodontic infections: a prospective, observational study

BACKGROUND

This study aimed to identify key symptoms that could be associated with the diagnosis of acute forms of symptomatic apical periodontitis (SAP) and symptomatic irreversible pulpitis (SIP), and to identify a diagnostic algorithm based on these symptoms.

METHODS

In this prospective, observational study 173 emergency patients diagnosed with acute pain of endodontic origin and no swelling or fistula were included. Patients were asked 11 specific questions from a checklist with a possible discerning value between acute SAP and acute SIP. Pain levels were recorded using the numeric rating scale (NRS-11). Subsequently, the painful tooth was diagnosed. Logistic regression was used to evaluate the checklist regarding its differentiation between SAP (N = 103) and SIP (N = 70). Moreover, a decision tree was constructed based on recursive partitioning to identify a hierarchy in differentiating symptoms.

RESULTS

With identical median NRS-11 scores of 8, the teeth diagnosed with acute SAP and SIP were severely painful. The decision tree analysis resulted in a tree with splits according to pain on cold, perceived tooth extrusion, and pain duration. The overall sensitivity of the tree to detect SAP based on key symptoms was 95 %, its specificity was 31 %.

CONCLUSIONS

The best indicator for SAP was a reported absence of pain to cold stimuli. In teeth that did have a history of pain triggered by cold stimuli, the decision tree correctly identified SAP in 72 % of the teeth that felt too high and had hurt for less than one week.

Effect of Premedication with Indomethacin and Ibuprofen on Postoperative Endodontic Pain: A Clinical Trial

INTRODUCTION

Post-endodontic pain is one of the main problems for both patients and dentists. The purpose of this study was to compare the effectiveness of premedication with indomethacin and ibuprofen for management of postoperative endodontic pain.

METHODS AND MATERIALS

In this clinical trial, mandibular molars with irreversible pulpitis were endodontically treated in 66 patients. The medicines were prepared similarly in the form of capsules containing 400 mg ibuprofen (group A), 25 mg indomethacin (group B) and placebo (group C). The patients were given one capsule 1 h before the start of treatment. Patients recorded their pain measured by a visual analogue scale (VAS) at medication time, during treatment and 8, 12 and 24 h after treatment. The data were analyzed using the chi-square, repeated measures ANOVA, paired t-test, Tamhane and Pearson correlation coefficient.

RESULTS

Ibuprofen and indomethacin significantly reduced the postoperative pain in comparison with placebo during treatment and 8 h after treatment; however, there were no significant differences between them 12 and 24 h after treatment.

CONCLUSION

Premedication with ibuprofen and indomethacin can effectively control short term post-operative pain; the lower incidence of side effects and greater analgesic power of ibuprofen make it a superior choice.