Associations between Pain Severity, Clinical Findings, and Endodontic Disease: A Cross-Sectional Study

Expression patterns of mechanosensitive ion channel PIEZOs in irreversible pulpitis

BACKGROUND

Mechanosensitive ion channel PIEZOs have been widely reported to involve inflammation and pain. This study aimed to clarify expression patterns of PIEZOs and their potential relations to irreversible pulpitis.

MATERIALS AND METHODS

Normal pulp tissues (n = 29) from patients with impacted third molars and inflamed pulp tissues (n = 23) from patients with irreversible pulpitis were collected. Pain levels were assessed using a numerical rating scale. PIEZO expressions were measured using real-time PCR and then confirmed using GEO datasets GSE77459, immunoblot, and immunohistochemistry staining. Correlations of PIEZO mRNA expression with inflammatory markers, pain markers, or clinical pain levels were evaluated using Spearman's correlation analysis. Univariate analysis was conducted to analyze PIEZO expressions based on pain description and clinical examinations of cold test, percussion, palpation, and bite test.

RESULTS

Compared with normal pulp tissues, mRNA expression levels of PIEZO1 were significantly increased in inflamed pulp tissues, while PIEZO2 was significantly decreased, which was further confirmed in GSE77459 and on a protein and histological level. The positive correlation of the mRNA expression levels between PIEZO1 and inflammatory markers, as well as between PIEZO2 and pain markers, was verified. PIEZO2 expression was also positively correlated with pain levels. Besides, irreversible pulpitis patients who reported continuous pain and who detected a positive response to cold stimulus exhibited a higher expression level of PIEZO2 in the inflamed pulp tissues. By contrast, patients reporting pain duration of more than one week showed a higher expression level of PIEZO1.

CONCLUSIONS

This study demonstrated the upregulation of PIEZO1 and the downregulation of PIEZO2 in irreversible pulpitis and revealed the potential relation of PIEZO1 and PIEZO2 to inflammation and pain. These findings suggested that PIEZOs might play critical roles in the progression of irreversible pulpitis and paved the way for further investigations aimed at novel therapies of irreversible pulpitis by targeting PIEZOs.

Paradigms matter: why persistent pain is different and how dentists can help

Dental professionals often expect, and are used to treating, pain that has a clear, organic and likely pathological cause. Patients visiting the dentist are also likely to share this expectation. However, in addition to potential organic contributions to the experience of pain, the nociceptive system (pain signalling system) also plays an important role. Alongside organic contributions, it is important to also consider that persistent pain is different to acute pain and requires different explanations and different management. Dental professionals need to be equipped to understand and explain persistent pain and to incorporate this understanding into their ongoing patient management so that patients can be educated in why the two are different and therefore require different approaches.

Efficacy of articaine anesthesia with needle-free/Comfort-in method and conventional needle injection in dental patients with irreversible pulpitis: a randomized clinical trial

OBJECTIVE

To assess the anesthetic efficacy of articaine with the needle-free/Comfort-in™ method compared to the conventional needle method. To assess pain during anesthesia application, onset of anesthesia and patient`s self-reported quality of life-related to oral health after the dental emergency appointment.

MATERIALS AND METHODS

This parallel, randomized clinical trial was conducted by a single operator/dentist in the state of Maranhao, northeast of Brazil. Included participants were adult dental patients with one molar (maxillary) or premolar (maxillary or mandibular) tooth diagnosed with symptomatic irreversible pulpitis. The primary outcome was the anesthetic efficacy, measured using a combination of electrical and cold pulp tests (cold + EPT) and the Numerical Rating Scale (NRS). Secondary outcomes were pain during anesthesia application, onset of anesthesia, and patient`s quality-of-life (measured with the OHIP-14).

RESULTS

62 patients were randomized in the anesthesia needle-free group and Comfort-in group (34.26 ± 10.786 × 33.29 ± 8.399 years old, respectively). The group of patients in the Comfort-in group had 71.0% success. Patients from the Comfort-in group reported statistically lower pain during the anesthesia application than patients from the conventional group (2.13 ± 2.172 × 6.03 ± 3.146 NRS scores, respectively) as well as immediately after the anesthetic procedure. Patients self-reported negative impact in quality of life was similar between groups before (p > 0.05) and after (p > 0.05) the dental emergency.

CONCLUSIONS

Comfort-in™ had similar efficacy to the conventional needle method.

CLINICAL RELEVANCE

This trial showed that it is possible to anesthetize patients with tooth pulpits without using needles to provide comfort mainly to anxious patients.

Patient-reported orofacial-dental pain severity and tele-triage decisions during COVID-19 pandemic: Does the severity of pain drive tele-triage decisions?

Background

Globally, with the COVID-19 pandemic, dental services were limited to emergency/ urgent conditions and were provided only after tele-triage referral for face-to-face management. However, no previous research explored whether the pain severity (PS) drives the tele-triage decisions. The current study examined the association between PS and tele-triage decision of whether to manage the condition remotely or refer the caller for face-to-face management.

Methods

This retrospective cross-sectional study analyzed the PS reported by hotline callers, using numerical rating scale (NRS-11), during the first wave of COVID-19 lockdown (23 March–31 August 2020) and its association with tele-triage decision controlling for age, sex, history of chronic illness, and dental discipline needed. Binomial logistic regression assessed the association between the PS (exposure) and tele-triage decision (outcome). ANOVA compared PS across tele-triage categories, dental history and tentative diagnosis.

Results

PS was significantly associated with tele-triage decisions (p < 0.05). An increase in pain score by 1 unit was associated with 1.4 times increased odds of face-face referral (95% CI: 1.26–1.54). Pediatric/ adolescent patients (9–18 years) (odds ratio (OR) = 2.07; 95% CI: 1.07–4.02), history of chronic illness (OR = 2.12; 95% CI:1.28–3.51), need for surgical specialty (OR = 1.93; 95% CI: 1.22–3.04) and orthodontic specialty (OR = 7.02; 95% CI: 3.54–13.87) were independently associated with tele-triage decision. PS was highest for the emergency triage category (8.00 ± 2.83, P < 0.0001), dental history of tooth with cavity or filling (6.65 ± 2.024, P < 0.0001), and the tentative tele-diagnosis of cellulitis (7.75 ± 2.872, P < 0.0001).

Conclusions

During COVID-19 pandemic, tele-triage decisions were significantly influenced by patient-reported PS, adjusting for a range of variables. Despite this, referral for face-to-face management was individualized and driven by the tripartite considerations of the reported pain, clinical judgement, and the high transmission characteristics of COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02340-w.

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.

A critical analysis of research methods and experimental models to study pulpitis

Pulpitis is the inflammatory response of the dental pulp to a tooth insult, whether it is microbial, chemical, or physical in origin. It is traditionally referred to as reversible or irreversible, a classification for therapeutic purposes that determines the capability of the pulp to heal. Recently, new knowledge about dental pulp physiopathology led to orientate therapeutics towards more frequent preservation of pulp vitality. However, full adoption of these vital pulp therapies by dental practitioners will be achieved only following better understanding of cell and tissue mechanisms involved in pulpitis. The current narrative review aimed to discuss the contribution of the most significant experimental models developed to study pulpitis. Traditionally, in vitro two(2D)- or three(3D)-dimensional cell cultures or in vivo animal models were used to analyse the pulp response to pulpitis inducers at cell, tissue or organ level. In vitro 2D cell cultures were mainly used to decipher the specific roles of key actors of pulp inflammation such as bacterial by-products, pro-inflammatory cytokines, odontoblasts or pulp stem cells. However, these simple models did not reproduce the 3D organisation of the pulp tissue and, with rare exceptions, did not consider interactions between resident cell types. In vitro tissue/organ-based models were developed to better reflect the complexity of the pulp structure. Their major disadvantage is that they did not allow the analysis of blood supply and innervation participation. On the contrary, in vivo models have allowed researchers to identify key immune, vascular and nervous actors of pulpitis and to understand their function and interplay in the inflamed pulp. However, inflammation was mainly induced by iatrogenic dentine drilling associated with simple pulp exposure to the oral environment or stimulation by individual bacterial by-products for short periods. Clearly, these models did not reflect the long and progressive development of dental caries. Lastly, the substantial diversity of the existing models makes experimental data extrapolation to the clinical situation complicated. Therefore, improvement in the design and standardization of future models, for example by using novel molecular biomarkers, databased models and artificial intelligence, will be an essential step in building an incremental knowledge of pulpitis in the future.