Effect of an intraosseous injection of depo-medrol on pulpal concentrations of PGE2 and IL-8 in untreated irreversible pulpitis

Comparing the Effects of Intramuscular Injections of Dexamethasone and Ketorolac Tromethamine on Post-treatment Endodontic Pain: An In Vivo Study

BACKGROUND AND OBJECTIVES

Pain is the primary reason dental patients seek endodontic therapy. Post-treatment endodontic discomfort is a sequelae of periapical inflammation and anti-inflammatory drugs such as corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) would be reasonable therapy options. The purpose of this study was to compare and assess the efficacy of intramuscular injections of dexamethasone and ketorolac tromethamine versus placebo in reducing post-treatment endodontic pain in individuals undergoing root canal treatment.

METHODOLOGY

Patients diagnosed with symptomatic irreversible pulpitis were selected. Nonsurgical endodontic therapy was carried out in a single visit. After completion of the root canal therapy, the patients were randomly assigned to one of the three groups for intramuscular drug administration. In group 1, 2 ml of sterile saline was administered, in group 2, 1 ml of 4 mg dexamethasone was administered; and in group 3, 1 ml of 30 mg ketorolac tromethamine was administered. Preoperative and postoperative pain intensity was measured by a verbal rating scale. Postoperatively, the incidence and severity of pain were recorded after four, 24, and 48 hours.

RESULTS

All three groups showed a highly statistically significant reduction in pain scores when compared to preoperative levels. At the end of four hours, dexamethasone and ketorolac tromethamine showed highly significant results. Dexamethasone significantly reduced pain after 24 hours when compared to ketorolac and placebo groups. At the conclusion of 48 hours, all three groups experienced a gradual decrease in pain levels.

CONCLUSION

Effective and complete debridement of infected root canal system provides predictable gradual reduction of post-endodontic pain.

Icariin negatively regulated lipopolysaccharide-induced inflammation and ameliorated the odontogenic activity of human dental pulp cells in vitro

Alleviating inflammation and promoting dentine regeneration is critical for the healing of pulpitis. In this study, we investigated the anti-inflammatory, angiogenesis and odontogenesis function of icariin on Human dental pulp cells (HDPCs) under inflammatory state. Furthermore, the underlying mechanisms was also evaluated. Icariin attenuated the LPS-induced pro-inflammatory marker expression, such as interleukin-1β (IL-1β), IL-6 and IL-8. The immunoblotting and immunofluorescence staining results showed that icariin suppressed the inflammatory responses mediated by the protein kinase B (Akt) and nuclear factor kappa-B (NF-κB) signaling cascades. Additionally, icariin also upregulated the expression of odontogenic and angiogenic genes and proteins (namely dentin sialophosphoprotein (DSPP), dentin matrix protein 1 (DMP1), anti-collagen Ⅰ (COL-Ⅰ), and vascular endothelial growth factor (VEGF) and fibroblast growth factor-1 (FGF-1)), alkaline phosphatase activity, and calcium nodule deposition in LPS-exposed HDPCs. In a word, our findings indicated that icariin attenuated pulp inflammation and promoted odontogenic and angiogenic differentiation in the inflammatory state. Icariin may be a promising vital pulp therapy agent for the regenerative treatment of the inflamed dental pulp.

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.

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.

Effect of non-steroidal anti-inflammatory drugs on pulpal and periapical inflammation induced by lipopolysaccharide

OBJECTIVES

The objective of this study was to evaluate the effect of non-steroidal anti-inflammatory drugs (NSAIDs) in controlling pulpal and periapical inflammation in vivo as a potential coadjutant systemic therapy for pulpitis.

MATERIALS AND METHODS

A suspension containing E. coli lipopolysaccharide (LPS; 1.0 μg/μL) was inoculated into the pulp chamber of the first molars of C57BL/6 mice (n = 72), and the animals were treated daily with indomethacin or celecoxib throughout the experimental periods. After 7, 14, 21, and 28 days, the tissues were removed for histopathological, histoenzymology, histometric, and immunohistochemical evaluation.

RESULTS

Inoculation of LPS into the pulp chamber induced the synthesis of the enzyme cyclooxygenase-2 (COX-2) in dental pulp and periapical region. Indomethacin and celecoxib treatment changed the profile of inflammatory cells recruited to dental pulp and to the periapex, which was characterized by a higher mononuclear cell infiltrate, compared to LPS inoculation alone which recruited a higher amount of polymorphonuclear neutrophils. Administration of indomethacin for 28 days resulted in the development of apical periodontitis and increased osteoclast recruitment, unlike celecoxib.

CONCLUSIONS

NSAIDs indomethacin and celecoxib changed the recruitment of inflammatory cells to a mononuclear profile upon inoculation of LPS into the pup chamber, but indomethacin enhanced periapical bone loss whereas celecoxib did not.

CLINICAL RELEVANCE

Celecoxib, a selective COX-2 inhibitor, can change the profile of inflammatory cells recruited to the dental pulp challenged with LPS and might a be potential systemic coadjutant for treatment of pulpitis.

Role(s) of cytokines in pulpitis: Latest evidence and therapeutic approaches

Pulpitis is known as a typical inflammation of dental pulp tissue, and microorganisms of the oral microbiome are involved in this opportunistic infection. Studies indicated that several factors related to host response have a crucial role in pulpitis. Among these factors, inflammatory mediators of the immune system such as cytokines and chemokines contribute to pulpal defense mechanisms. A wide range of cytokines have been observed in dental pulp and these small molecules are able to trigger inflammation and participate in immune cell trafficking, cell proliferation, inflammation, and tissue damage in pulp space. Therefore, the aim of this review was to describe the role of cytokines in the pathogenesis of pulpitis.

Betamethasone suppresses the inflammatory response in LPS-stimulated dental pulp cells through inhibition of NF-κB

OBJECTIVE

This study aimed to investigate the anti-inflammatory effect of betamethasone on LPS-stimulated human dental pulp stem cells (DPSCs) and its associated mechanism. The osteo-/odontogenic differentiation and osteoclast effect of betamethasone on DPSCs and stem cells from human exfoliated deciduous teeth (SHED) were evaluated.

DESIGN

The proliferative effect of betamethasone on DPSCs was analyzed using a cholecystokinin octapeptide assay. The anti-inflammatory effect of betamethasone was investigated using quantitative polymerase chain reaction (qPCR) and ELISA. The anti-inflammatory mechanism was explored using qPCR, Western blot, and immunofluorescence staining. The osteo-/odontogenic differentiation and osteoclast effect of betamethasone on DPSCs and SHED were detected by qPCR.

RESULTS

1 μg L^-1 betamethasone was found to have the strongest effect on DPSCs proliferation. The expression of pro-inflammatory cytokines and mediators, as well as prostaglandin E₂ (PGE₂) were significantly decreased following treatment with betamethasone in LPS- stimulated DPSCs. They were also decreased in response to an NF-κB inhibitor, Bay 11-7082. Betamethasone and Bay 11-7082 significantly inhibited the expression of p-p65 and promoted the nuclear exclusion of p65. Gene expression associated with osteo-/odontogenic differentiation was significantly up-regulated in betamethasone and osteogenic media (OM) treated groups. The ratio of the receptor activator of nuclear factor kappa B ligand (RANKL) and osteoprotegerin (OPG) at the mRNA level was suppressed in DPSCs and elevated in SHED.

CONCLUSIONS

Betamethasone has an anti-inflammatory effect on LPS- stimulated DPSCs through a blockade of NF-κB activation and exhibits an osteo-/odonto-inductive effect on DPSCs and SHED. Although betamethasone displays an osteoclast effect on SHED.

Efficacy of orally administered prednisolone versus partial endodontic treatment on pain reduction in emergency care of acute irreversible pulpitis of mandibular molars: study protocol for a randomized controlled trial

BACKGROUND

Irreversible pulpitis is a highly painful inflammatory condition of the dental pulp which represents a common dental emergency. Recommended care is partial endodontic treatment. The dental literature reports major difficulties in achieving adequate analgesia to perform this emergency treatment, especially in the case of mandibular molars. In current practice, short-course, orally administered corticotherapy is used for the management of oral pain of inflammatory origin. The efficacy of intraosseous local steroid injections for irreversible pulpitis in mandibular molars has already been demonstrated but resulted in local comorbidities. Oral administration of short-course prednisolone is simple and safe but its efficacy to manage pain caused by irreversible pulpitis has not yet been demonstrated. This trial aims to evaluate the noninferiority of short-course, orally administered corticotherapy versus partial endodontic treatment for the emergency care of irreversible pulpitis in mandibular molars.

METHODS/DESIGN

This study is a noninferiority, open-label, randomized controlled clinical trial conducted at the Bordeaux University Hospital. One hundred and twenty subjects will be randomized in two 1:1 parallel arms: the intervention arm will receive one oral dose of prednisolone (1 mg/kg) during the emergency visit, followed by one morning dose each day for 3 days and the reference arm will receive partial endodontic treatment. Both groups will receive planned complete endodontic treatment 72 h after enrollment. The primary outcome is the proportion of patients with pain intensity below 5 on a Numeric Scale 24 h after the emergency visit. Secondary outcomes include comfort during care, the number of injected anesthetic cartridges when performing complete endodontic treatment, the number of antalgic drugs and the number of patients coming back for consultation after 72 h.

DISCUSSION

This randomized trial will assess the ability of short-term corticotherapy to reduce pain in irreversible pulpitis as a simple and rapid alternative to partial endodontic treatment and to enable planning of endodontic treatment in optimal analgesic conditions.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02629042 . Registered on 7 December 2015. (Version n°1.1 28 July 2015).

Effect of Dexamethasone Intraligamentary Injection on Post-Endodontic Pain in Patients with Symptomatic Irreversible Pulpitis: A Randomized Controlled Clinical Trial

Introduction:

The aim of this randomized-controlled clinical trial was to assess the effect of intraligamentary (PDL) injection of dexamethasone on onset and severity of post-treatment pain in patients with symptomatic irreversible pulpitis.

Methods and Materials:

A total number of 60 volunteers were included according to the inclusion criteria and were assigned to three groups (n=20). After administration of local anesthesia and before treatment, group 1 (control) PDL injection was done with syringe containing empty cartridge, while in groups 2 and 3 the PDL injection was done with 0.2 mL of 2% lidocaine or dexamethasone (8 mg/2 mL), respectively. Immediately after endodontic treatment patients were requested to mark their level of pain on a visual analogue scale (VAS) during the next 48 h (on 6, 12, 24 and 48-h intervals). They were also asked to mention whether analgesics were taken and its dosage. Considering the 0-170 markings on the VAS ruler, the level of pain was scored as follows: score 0 (mild pain; 0-56), score 1 (moderate pain; 57-113) and score 3 (severe pain; 114-170). The data were analyzed using the Kruskal-Wallis and the Chi-square tests and the level of significance was set at 0.05.

Results:

After 6 and 12 h, group 1 and group 3 had the highest and lowest pain values, respectively (P<0.01 and P<0.001 for 6 and 12 h, respectively). However, after 24 and 48 h the difference in the pain was not significant between groups 1 and 2 (P<0.6) but group 3 had lower pain levels (P<0.01 and P<0.8 for 24 and 48 h, respectively).

Conclusion:

Pretreatment PDL injection of dexamethasone can significantly reduce the post-treatment endodontic pain in patients with symptomatic irreversible pulpitis.

Pain Reduction in Untreated Symptomatic Irreversible Pulpitis Using Liposomal Bupivacaine (Exparel): A Prospective, Randomized, Double-blind Trial

INTRODUCTION

In the treatment of patients with symptomatic irreversible pulpitis, endodontic debridement is a predictable method to relieve pain. However, there are clinical situations in which emergency care cannot be provided immediately. An unexplored treatment option in these cases may be the use of a long-acting anesthetic to reduce pain in untreated irreversible pulpitis. Some medical studies have shown potential for infiltrations of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, San Diego, CA) to prolong pain relief and reduce opioid use postoperatively. The Food and Drug Administration has approved Exparel only for infiltrations; therefore, the purpose of this study was to compare an infiltration of liposomal bupivacaine versus bupivacaine for pain control in untreated, symptomatic irreversible pulpitis.

METHODS

Ninety-five emergency patients received 2% lidocaine with 1:100,000 epinephrine via infiltration or an inferior alveolar nerve block to relieve their initial presenting pain. Patients then randomly received either 4 mL liposomal bupivacaine (13.3 mg/mL) or 4 mL 0.5% bupivacaine with 1:200,000 epinephrine by infiltration. Patients received a diary for the day of the appointment and 3 days postinjection to record soft tissue numbness, pain levels, and analgesic (non-narcotic and narcotic) use.

RESULTS

No significant differences (P < .05) were found between the 2 anesthetic formulations for pain or the use of pain medications. A statistically higher level of soft tissue numbness was found on days 1 to 3 for the liposomal bupivacaine group.

CONCLUSIONS

Although liposomal bupivacaine had some effect on soft tissue anesthesia, it did not reduce pain to manageable clinical levels in patients presenting with untreated, symptomatic irreversible pulpitis.

Dental pulp cells promote the expression of receptor activator of nuclear factor-κB ligand, prostaglandin E2 and substance P in mechanically stressed periodontal ligament cells

OBJECTIVE

This study investigated the expression of receptor activator of nuclear factor-κB ligand (RANKL) in periodontal ligament (PDL) cells co-cultured with dental pulp (DP) cells following mechanical stress in vitro. Furthermore, the expression of prostaglandin (PG) E₂ and substance P (SP) by the PDL cells and by the DP cells were also examined.

DESIGN

PDL and DP cells were obtained from 10 rats. The experimental group consisted of PDL cells subjected to centrifugal force as mechanical stress and co-cultured with DP cells. The 3 control groups of PDL cells were: 1) PDL cells without mechanical stress, 2) PDL cells treated with mechanical stress and 3) PDL cells co-cultured with DP cells. The 2 control groups of DP cells were: 1) DP cells without mechanical stress and 2) DP cells co-cultured with PDL cells. In each group, both cells were examined at day 1 and day 3, and mRNA levels of RANKL by PDL cells were analyzed using Real time quantitative Reverse Transcription (RT)-PCR. Furthermore, RANKL expression was observed using Immunofluorescence staining. PGE₂ and SP expression levels by PDL cells and DP cells were characterized by ELISA analysis.

RESULTS

The expression of RANKL by PDL cells under mechanical stress increased by co-culture with DP cells. PGE₂ and SP expressions were increased in the group of PDL cells subjected to mechanical stress and co-cultured with DP cells.

CONCLUSION

DP cells may facilitate the expression of RANKL in PDL cells under mechanical stress via PGE₂ and SP.

Peripheral mechanisms of odontogenic pain

In this article, we review the key basic mechanisms associated with this phenomena and more recently identified mechanisms that are current areas of interest. Although many of these pain mechanisms apply throughout the body, we attempt to describe these mechanisms in the context of trigeminal pain.

Drugs for pain management in dentistry

Pain is one of the most common reasons patients seek dental treatment. It may be due to many different diseases/conditions or it may occur after treatment. Dentists must be able to diagnose the source of pain and have strategies for its management. The '3-D's' principle--diagnosis, dental treatment and drugs--should be used to manage pain. The first, and most important, step is to diagnose the condition causing the pain and identify what caused that condition. Appropriate dental treatment should then be undertaken to remove the cause of the condition as this usually provides rapid resolution of the symptoms. Drugs should only be used as an adjunct to the dental treatment. Most painful problems that require analgesics will be due to inflammation. Pain management drugs include non-narcotic analgesics (e.g., non-steroidal anti-inflammatory drugs, paracetamol, etc) or opioids (i.e., narcotics). Non-steroidal anti-inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti-inflammatory and analgesic action. The most common NSAIDs are aspirin and ibuprofen. Paracetamol gives very effective analgesia but has little anti-inflammatory action. The opioids are powerful analgesics but have significant side effects and therefore they should be reserved for severe pain only. The most commonly-used opioid is codeine, usually in combination with paracetamol. Corticosteroids can also be used for managing inflammation but their use in dentistry is limited to a few very specific situations.

The Effect of Endodontic Therapy on Periapical Exudate Neutrophil Elastase and Prostaglandin-E2 Levels

This study aimed to investigate periapical exudate neutrophil elastase (NE) and prostaglandin E2 (PGE2) levels and their relationships with clinical symptoms, and to determine the changes of their levels following first treatment visit. Periapical exudate samples were collected from the canals of 34 nonvital single-rooted teeth at two sequential treatment visits. Periapical exudate NE and PGE2 levels were found to be higher in the presence of clinical symptoms (pus discharge, swelling) (p < 0.05). The canals of teeth with larger periapical radiolucent area (>or=1 cm) contained more PGE2 levels than with smaller ones (<1 cm) (p < 0.05). Periapical exudate NE levels were significantly correlated with PGE2 levels (p < 0.05), and their levels at first treatment visit did not change following root canal therapy (p > 0.05). The periapical exudate NE and PGE2 levels may regulate periapical disease expression, but the results of this study were unable to reveal this association.

Induction of Interleukin-6 and Interleukin-8 Gene Expression by Root Canal Sealers in Human Osteoblastic Cells

Histological investigations have demonstrated that root canal sealers can induce mild to severe inflammatory alternations. However, there is little information on the precise mechanisms about root canal sealers-induced inflammatory reaction. Dysregulated cytokine productions at local disease sites have been considered to be major contributors to the development of inflammatory diseases. Interleukin (IL)-6 and IL-8 released have been reported to play an important role in the pathogenesis of inflammation. The aim of this study was to investigate the effects of root canal sealers N2 (zinc-oxide eugenol based) and AH Plus (epoxy resin based) on the expression of IL-6 and IL-8 mRNA gene in human osteoblastic cell line U2OS cells. The levels of mRNAs were measured by the semi-quantitative reverse-transcriptase polymerase chain reaction analysis. The exposure of quiescent U2OS cells to N2 and AH Plus resulted in the induction of IL-6 and IL-8 mRNA gene expression (p < 0.05). The intensity of IL-8 mRNA gene was found to be significant higher than IL-6 mRNA gene (p < 0.05). Taken together, the activation of IL-6 and IL-8 mRNA gene expression may be one of the pathogenesis of zinc oxide-eugenol based and epoxy resin based root canal sealers-induced periapical inflammation.