Analysis of interappointment pain associated with the combined use of endodontic irrigants and medicaments

Evaluation of postoperative pain after endodontic treatment with foraminal enlargement and obturation using two auxiliary chemical protocols

Aim This prospective randomized clinical study examined the influence of two different auxiliary chemical substances on postoperative pain in 301 single-visit endodontic treatments, with enlargement of the apical foramen and extrusion of cement into the periapical region. Material and method The two auxiliary chemicals used were 2% chlorhexidine (2% CHX gel; n = 145) and 5.25% sodium hypochlorite (5.25% NaOCl; n = 156). The incidence of postoperative pain and discomfort was assessed at 24 hours and expressed as percentages. The Fisher exact test and the Chi-square test were used to compare variation in postoperative pain. The variables analyzed were previous pain, pulp status, age, and number of root canals. Result In teeth with previous pain instrumented with 2% CHX gel, the incidence of postoperative pain was 22.22% (6/27) versus 11.11% (3/22) in teeth instrumented with 5.25% NaOCl. In teeth without previous pain instrumented with 2% CHX gel, the incidence of postoperative pain was 8.5% (6/118) versus 2.33% (3/129) in teeth instrumented with 5.25% NaOCl, with no statistically significant difference between the groups. Results showed that previous pain had a significant influence on postoperative status (p < 0.001). After 24 hours postoperatively, 93.7% (282/301) of the teeth had no pain and 6.3% (19/301) had some level of pain, and used one or two doses of medication. Conclusion Based on the results, it can be concluded that the auxiliary chemical substances had no influence on postoperative pain.

Postoperative pain after root canal treatment: a prospective cohort study

Aim. To evaluate the incidence and severity of postendodontic treatment pain (PEP) subsequent to root canal treatment (RCT) in vital and necrotic pulps and after retreatment. Methodology. A prospective study. Participants were all patients (n = 274) who underwent RCT in teeth with vital pulp, necrotic pulp, or vital pulp that had been treated for symptomatic irreversible pulpitis or who received root canal retreatment, by one clinician, during an eight-month period. Exclusion criteria were swelling, purulence, and antibiotic use during initial treatment. A structured questionnaire accessed age, gender, tooth location, and pulpal diagnosis. Within 24 h of treatment, patients were asked to grade their pain at 6 and 18 hours posttreatment, using a 1–5 point scale. Results. RCT of teeth with vital pulp induced a significantly higher incidence and severity of PEP (63.8%; 2.46 ± 1.4, resp.) than RCT of teeth with necrotic pulp (38.5%; 1.78 ± 1.2, resp.) or of retreated teeth (48.8%; 1.89 ± 1.1, resp.). No statistical relation was found between type of pain (spontaneous or stimulated) and pulp condition. Conclusion. RCT of teeth with vital pulp induced a significantly higher incidence and intensity of PEP compared to teeth with necrotic pulp or retreated teeth.

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.

Prevalence of and factors affecting postpreparation pain in patients undergoing two-visit root canal treatment

AIM

This longitudinal, prospective study (i) investigated the prevalence of postpreparation pain during root canal treatment and (ii) evaluated the influence of factors affecting the pain experience.

METHODOLOGY

Twenty practitioners, comprising general dental practitioners, MSc graduates and endodontists, participated in this study. The patient sample (n=272) was derived from consecutive patients attending the practitioners' surgeries for a two-visit root canal treatment on a single tooth. Demographic, medical history, preoperative and intraoperative data as well as pain experience on days 1 and 2 after root canal preparation were recorded. Intensity of pain experienced was recorded on a visual analogue scale (VAS) of 0-5. The data were analysed using logistic regression models.

RESULTS

The prevalence of postpreparation pain within 48 h after treatment was 64.7% (n=176), but less than 10% of patients experienced severe pain (VAS 4 or 5) on either day 1 or day 2. The presence of preoperative pain (OR=2.841, P<0.001), tooth type (OR=2.008, P=0.009), systemic steroid therapy for other medical reasons (OR=0.181, P=0.023) and preoperative swelling (OR=2.433, P=0.040) were the only factors to significantly influence postpreparation pain experience.

CONCLUSIONS

The prevalence of postpreparation pain was high, and the important prognostic determinants were presence of preoperative pain, tooth type, systemic steroid therapy and preoperative swelling.

Microbial causes of endodontic flare-ups

LITERATURE REVIEW

Inter-appointment flare-up is characterized by the development of pain, swelling or both, following endodontic intervention. The causative factors of flare-ups encompass mechanical, chemical and/or microbial injury to the pulp or periradicular tissues. Of these factors, microorganisms are arguably the major causative agents of flare-ups. Even though the host is usually unable to eliminate the root canal infection, mobilization and further concentration of defence components at the periradicular tissues impede spreading of infection, and a balance between microbial aggression and host defences is commonly achieved. There are some situations during endodontic therapy in which such a balance may be disrupted in favour of microbial aggression, and an acute periradicular inflammation can ensue. Situations include apical extrusion of infected debris, changes in the root canal microbiota and/or in environmental conditions caused by incomplete chemo-mechanical preparation, secondary intraradicular infections and perhaps the increase in the oxidation-reduction potential within the root canal favouring the overgrowth of the facultative bacteria. Based on these situations, preventive measures against infective flare-ups are proposed, including selection of instrumentation techniques that extrude lesser amounts of debris apically; completion of the chemo-mechanical procedures in a single visit; use of an antimicrobial intracanal medicament between appointments in the treatment of infected cases; not leaving teeth open for drainage and maintenance of the aseptic chain throughout endodontic treatment. Knowledge about the microbial causes of flare-ups and adoption of appropriate preventive measures can significantly reduce the incidence of this highly distressing and undesirable clinical phenomenon.

Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy

The purpose of this prospective study was to evaluate the incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. Data were examined from 627 teeth that had necrotic pulps or required retreatment. Information was obtained for each patient treated with regard to presence of preoperative pain. Occurrence of periradicular bone destruction detected by radiographs was also recorded. The operators consisted of undergraduate students, who were in their first year of clinical training. Root canals were instrumented and then medicated with a calcium hydroxide/camphorated paramonochlorophenol paste. No systemic medication was prescribed. Approximately 1 week after the initial appointment, patients were asked about the occurrence of postoperative pain and the level of discomfort was rated as no pain, mild pain, moderate pain, or severe pain. Data were statistically analyzed using the Chi-square test. Mild pain occurred in 10% of the cases, moderate in 3.3%, and severe (flare-up) in 1.9%. Postoperative pain was significantly associated with the treatment of previously symptomatic teeth without periradicular lesions (p < 0.01). No other correlations were detected between the occurrence of postoperative discomfort and other clinical conditions. There was also no difference regarding the incidence of postoperative pain between treatment and retreatment (p > 0.01). The intracanal procedures used in this study to control root canal infections showed a small incidence of postoperative pain, particularly flare-ups, even performed by inexperienced undergraduate dental students.

Interappointment emergencies in teeth with necrotic pulps

The incidence of interappointment emergencies in symptomatic and asymptomatic teeth with necrotic pulps was evaluated, and severity of flare-ups was determined by a quantitative method using a flare-up index. There were no significant differences in the incidence of flare-ups attributable to gender, age, diameter of lesion, taking analgesics, placebos, or no medication, or preoperative symptomatic or asymptomatic tooth diagnoses (p > 0.05). There were significantly more painful flare-ups in mandibular teeth than in maxillary (p < 0.05).

Prevention of apical periodontal ligament pain: a preliminary report of 100 vital pulp cases

A preliminary study was conducted in a private practice office to determine the incidence of postoperative pain in 100 vital pulp cases. An ophthalmic dexamethasone-neomycin solution was introduced within the root canal during the complete cleaning and shaping procedure with the purpose of premedicating and preventing apical periodontal ligament inflammation and pain. The postoperative pain outcome was compared between cases premedicated with intracanal dexamethasone-neomycin solution alone and in combination with an oral administration of Mesulide. Moderate pain was reported in 10 cases and tooth sensitivity in 13. The clinical results indicated no report of severe pain.

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.

Delayed root canal therapy: an analysis of treatment over time

A retrospective study of 898 teeth receiving root canal therapy was performed to document the sequelae of delayed completion of root canal treatment. Teeth were categorized into a prompt treatment group and a delayed treatment group. Comparisons of prompt and delayed treatment groups were made with regard to preoperative pain, interappointment emergencies, postobturation pain, and final treatment. Findings from this study show that a palliative endodontic procedure is an extremely effective treatment. However, 56% of teeth with incomplete root canal therapy eventually were extracted compared with 2 to 3% for the root canal filling treatment groups. By emphasizing the potential loss of the tooth rather than the potential of interappointment emergencies, the clinician may be more effective in achieving compliance among patients receiving delayed treatment.

Postoperative pain incidence related to the type of emergency treatment of symptomatic pulpitis

Some endodontic emergencies occur as a result of attempts to relieve symptoms of pulpitis. The aim of this study was to identify any predictor of postoperative pain in a patient population treated by dental students. Patients who reported for treatment of symptomatic pulpitis were subjected to three different emergency treatment regimens. Clinical data was collected on those patients who reported in the emergency service with severe postoperative pain within 24 hours of emergency endodontic treatment. Statistical analysis of these data suggested that the type of endodontic emergency procedure carried out was a significant predictor of severe postoperative pain.

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.

Hypersensitivity to sodium hypochlorite

Sodium hypochlorite (NaOCl), the most commonly used irrigant in endodontics, is known to produce allergic reactions. This fact, however, is rarely mentioned in endodontic texts. Until now, only two cases of adverse reaction describing accidental injection of NaOCl have been reported. In the current study a case is presented in which hypersensitivity to household bleach was proven with skin patch tests. The clinician was warned of the possible health hazard from using NaOCl in this patient by the past medical history. Endodontic therapy was carried out with an irrigant not containing NaOCl after the allergy to NaOCl was verified. Treatment was uneventful. It is suggested that before any endodontic treatment in which sodium hypochlorite is to be used, the patient should be asked about hypersensitivity to household bleaching materials.

Effect of occlusal relief on endodontic pain

It has been suggested that removal of occlusion contacts will prevent or reduce postoperative endodontic pain during treatment. However, this theory has not been tested in clinical experiments. In this study, after endodontic instrumentation, the treated posterior tooth randomly received occlusal relief or mock-occlusal relief. Mean pain levels and the incidence of pain to occlusal pressure at various time intervals were recorded on questionnaire postcards by all patients, as was the duration of discomfort. Comparison of pain experienced by the occlusal treatment groups through statistical analysis gave the following conclusions: Spontaneous pain levels in the mock-occlusal relief and occlusal relief groups were not significantly different; Spontaneous pain levels in the mock-occlusal relief and occlusal relief groups did significantly relate to preoperative pain; Pain incidence from occlusal pressure in the mock-occlusal relief and occlusal relief groups did not significantly differ; Pain from occlusal pressure in both occlusal treatment groups did not significantly relate to preoperative pain; Duration of discomfort was not related to the occlusal treatment provided. The theory may be invalid that prophylactic removal of occlusal contacts is a pain preventive measure.