Effects of formocresol on posttreatment pain of endodontic origin in vital molars

Flare-ups in Endodontics: II. Therapeutic Measures

Various treatment regimens for the relief of pain during endodontic therapy, including relief of occlusion, pre-medication, establishment of drainage, and intracanal and systemic medications are presented. In addition, the rationale for the use of placebos is discussed.

Clinical implications of the smear layer in endodontics: a review

It has been recognized for many years that root canal instrumentation produces a smear layer that covers the surfaces of prepared canal walls. This layer contains inorganic and organic substances such as fragments of odontoblastic processes and necrotic debris. There is a lack of agreement regarding the effect of the smear layer on the quality of instrumentation and obturation, but the smear layer itself may be infected and may protect the bacteria within the dentinal tubules. Various methods have been used to remove the smear layer. Conflicting results have been obtained from numerous in vitro studies regarding the significance of the presence or the removal of the smear layer.

Effect of intracanal use of nonsteroidal anti-inflammatory agents on posttreatment endodontic pain

The ability of intracanal use of two nonsteroidal anti-inflammatory agents--diclofenac and ketoprofen--with and without hyaluronidase to control posttreatment pain was compared with that of a placebo control in a double-blind study of 760 subjects. The study was carried out on originally asymptomatic and symptomatic teeth that required endodontic therapy. Endodontic treatment was completed in three visits during which medications were placed into the canal either at the end of the first visit (postextirpation) or the second visit (postinstrumentation). Patients subjectively rated their pain on a scale of 1 to 4 as none, mild, moderate, and severe. The ratings were done preoperatively and at 2, 4, 8, and 12 hours postoperatively on the first day as well as on the second and third days. Statistical analysis of the data revealed that both diclofenac and ketoprofen significantly reduced the mean pain score in originally asymptomatic and symptomatic cases and were significantly superior to the placebo until the end of the study. Postendodontic pain occurred with less frequency when the teeth were treated with diclofenac, but diclofenac-treated and ketoprofen-treated cases were not significantly different at controlling postendodontic pain. An increase in the number of patients who reported complete absence of pain was recorded when hyaluronidase was added to the study medications. However, the difference between the medications and medications-hyaluronidase was not of statistical significance.

Incidence of interappointment emergency associated with endodontic therapy

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

The role of intracanal medication in root canal treatment

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

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

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

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

To determine whether a relatively large dose of oral dexamethasone given for a short period of time would be effective in reducing endodontic interappointment pain, the current double-blind, placebo-controlled study was undertaken. After the visit for instrumentation, 40 patients with asymptomatic teeth having vital-inflamed pulps were randomly given either dexamethasone (3 tablets of 4 mg each) or a dextrose placebo identical in appearance (same dosage schedule). The outcome showed that the oral administration of dexamethasone resulted in a statistically significant reduction in endodontic interappointment pain at all three time periods evaluated, that is, at 8 hours, 24 hours, and 48 hours (p less than 0.01). It appears from the results of this study that this dosage schedule of oral dexamethasone is sufficient to significantly reduce endodontic interappointment pain for teeth with asymptomatic vital-inflamed pulps. Further studies are needed for teeth with other endodontic pulpal-periapical conditions and for symptomatic teeth.

Management of posttreatment endodontic pain with oral dexamethasone: a double-blind study

In a double-blind study, twenty-five subjects who received oral dexamethasone and twenty-five placebo subjects rated their postoperative pain 8 and 24 hours following initial endodontic treatment. The subjects who received dexamethasone reported statistically significantly less postoperative pain than the subjects who received the placebos. The question is raised as to whether oral corticosteroids are appropriate for routine management of posttreatment endodontic pain.

Incidence of postoperative pain after single- and multiple-visit endodontic procedures

A series of 359 endodontic cases were followed and evaluated by the frequency of reported postoperative pain. A statistical analysis of the data obtained attempted to identify a relationship between pain experienced and the anatomic location, the pulpal vitality as determined by hemorrhage, or the number of treatment visits used in completing the case. Data obtained indicated no relationship between pain experience and pulpal vitality, no statistically significant relationship to the anatomic location, and a significant relationship to the number of visits used. The data indicate a 2 to 1 higher frequency of pain reported following treatment completed in multiple visits as compared to that reported for those completed in one visit.

Pain: a poor parameter of evaluation in dentistry

In summary, we must be aware of the limitations of our instruments for determining success. A diagnosis is achieved by developing a composite picture through a keen gathering of all factors leading to the disease. Pain must surely be considered in patient management and patient-dentist rapport, but to allow our judgment to be swayed by pain alone is no more rational than to hinge our diagnosis upon a single other test. It is of paramount importance that we realize that, pulpally, periodontally, and periapically, there is no correlation between amount of destruction and reported presence or absence of pain. Pain is a poor parameter of evaluation.