Drugs for pain management in dentistry

The influence of intraoral cryotherapy on postoperative pain and substance P in symptomatic apical periodontitis: randomized clinical study

Cryotherapy is widely utilized in medicine, particularly for pain management. This randomized clinical trial aimed to assess the effect of intraoral cold pack application (cryotherapy) on postoperative pain (POP) and the level of Substance P (SP) in patients with symptomatic apical periodontitis (SAP). Enrolled patients were randomly assigned to either cryotherapy or control group. After adequate anesthesia, access cavity, and biomechanical preparation of the root canal system were completed, the first apical fluid (AF) sample (S1) was obtained. A custom-made intraoral ice-gel pack was applied for 30 min in the cryotherapy group, while no intervention was performed in the control group. The second AF sample (S2) was collected 30 min later in both groups. Patients were asked to complete the Visual Analogue Scale (VAS) questionnaire to assess their POP. Quantification of SP in AF samples was performed using the enzyme-linked immunosorbent assay (ELISA) test. Data were analyzed statistically, revealing a significant reduction in POP and SP levels in the cryotherapy group compared to the control group (P ≤ 0.05). Furthermore, a moderate positive correlation was observed between SP levels and POP (P ≤ 0.05). In conclusion, intraoral cryotherapy represents a simple and cost-effective option for controlling POP and reducing inflammation levels in patients with SAP.

Effect of preemptive use of a nonsteroidal anti-inflammatory drug and a corticosteroid on the efficacy of inferior alveolar nerve blockade and postoperative pain control in endodontic treatment of molars with symptomatic pulpitis: A randomized double-blind placebo-controlled clinical trial

AIM

The anaesthetic success rate of an inferior alveolar nerve block (IANB) in mandibular molars with irreversible symptomatic pulpitis can be low, and postoperative pain control in teeth with this diagnosis can be challenging. This study aimed to evaluate the influence of preemptive use of dexamethasone and oral potassium diclofenac on the success of IANB. The influence of these drugs on the intensity of postoperative pain was assessed as a secondary outcome.

METHODOLOGY

Eighty-four patients with mandibular molars diagnosed with irreversible symptomatic pulpitis recorded preoperative pain intensity using a cold thermal test and a modified Numerical Rating Scale (mNRS). Sixty minutes before the anaesthetic procedure, patients were randomly assigned to one of three groups based on the medication they received: dexamethasone (4 mg), diclofenac potassium (50 mg), or placebo. All patients received IANB with 4% articaine (1:200 000 epinephrine), and 15 min later, they were evaluated for pain intensity using the cold thermal test. Anaesthetic success was analysed. The pain intensity was then recorded, and endodontic treatment and provisional restoration of the tooth were executed in a single session. Patients were monitored for 6, 12, 24, 48 and 72 h using the mNRS to assess the intensity of postoperative pain.

RESULTS

There was a statistically significant increase in anaesthetic success when 4 mg dexamethasone (39.3%) or 50 mg diclofenac potassium (21.4%) was used compared to the placebo group (3.6%) (p < .001), with no significant difference between the two drugs. Regarding postoperative pain, dexamethasone was superior to placebo at 6 h (p < .001), with diclofenac having an intermediate behaviour, not differing between dexamethasone and placebo (p > .05). There was no significant difference amongst the groups at 12 h (p > .05). At 24, 48 and 72 h, the effectiveness of dexamethasone and diclofenac were comparable, and both were superior to placebo (p < .001).

CONCLUSION

The use of dexamethasone or diclofenac potassium was favourable in terms of increasing the success rate of inferior alveolar nerve block in cases of mandibular molars with irreversible symptomatic pulpitis and decreased the occurrence of postoperative pain when compared to the use of a placebo.

Efficacy and safety of ibuprofen gargle for postoperative pain after mandibular third molar extraction: A phase II, placebo-controlled, double-blind, randomized crossover trial

OBJECTIVE

This study was designed to evaluate the postoperative efficacy and safety of using an ibuprofen gargle as a pain management strategy for patients who have undergone mandibular third molar extraction. We also ensured that the quality of treatment was not compromised throughout the study.

MATERIAL AND METHODS

Patients were randomized in a 1:1 ratio into two groups: the ibuprofen-placebo (IP) group and the placebo-ibuprofen (PI) group. On postoperative Day (POD) 1, the IP group initiated ibuprofen administration, while the PI group started taking placebo. On POD 2, the IP group switched to using placebo, whereas the PI group switched to ibuprofen. From PODs 3-5, both groups were prescribed ibuprofen gargle. The primary endpoint was within-subject visual analog scale (VAS) score before and 5 min after the first use of the ibuprofen or placebo gargle on PODs 1 and 2 (ΔVAS5_ibuprofen  - ΔVAS5_placebo ). The incidence and severity of adverse events were assessed using the Common Terminology Criteria for Adverse Events version 5.0 and a subjective rating scale.

RESULTS

This study enrolled 40 patients. The within-subject VAS5 of the IP and PI groups were 1.25 ± 12.0 and -5.26 ± 8.93 mm, respectively. The treatment effect of ibuprofen gargle was -2.01 ± 10.62 mm (p = .246). None of the patients in each group presented with serious adverse events or clinically significant complications (including dry sockets) after extraction. Transient adverse events, such as throat tingling and oral discomfort (grade 1), were observed in each group.

CONCLUSION

Ibuprofen gargle was safe but did not provide significant pain relief when used after mandibular third molar extraction.

Xenotransplantation of Microencapsulated Parathyroid Cells as a Potential Treatment for Autoimmune-Related Hypoparathyroidism

OBJECTIVES

Hypoparathyroidism occurs as a part of a complex autoimmune syndrome or iatrogenically after neck surgery. The disease presents many challenges, such as hypocalcemia, hyperphosphatemia, and low/undetectable parathormone levels. Allotransplantation of parathyroid tissue or cells has been reported as a promising option to overcome these effects. Transplantation of microencapsulated parathyroid tissue or cells offers an immune escape, which particularly restores the parathyroid function for autoimmune-related hypoparathyroidism. So far, clinical and in vivo studies have demonstrated limited graft survival and instability for the available biocompatible materials. In addition, the transplant site, proper local isolation, and biocompatibility of materials are directly related to survival rate.

MATERIALS AND METHODS

A microencapsulated parathyroid xenotransplant model by using high guluronic acid-containing ultrapure alginate transplanted into rat omentum was tested in vivo for 1 year.

RESULTS

After stability of empty microcapsules was ensured, parathyroid cells were microencapsulated and transplanted in rats, with results compared versus rats with naked (nonencapsulated) parathyroid cells (both groups followed for 64 weeks). Rats remained normocalcemic, and preinflammatory cytokine levels showed dramatic changes. Despite a delay posttransplant, parathormone levels increased significantly. All retrieved microencapsules elicited pericapsular fibrotic overgrowth; however, the fibrosis area was shown to be well tolerated.

CONCLUSIONS

The possible role of accumulation/cell infiltration of immune response remains to be elucidated. In conjunction with this, the use of nonencapsulated parathyroid cells was also positively correlated with survival rates. A similar evaluation using ultrapure alginate materials and omental transplantation may enable the future determination for the long-term effects of correction of parathormone insufficiency in patients with severe hypocalcemic responses and other endocrine diseases.

Pain management in periodontal therapy using local anesthetics and other drugs: an integrative review

Background

Surgical and non-surgical periodontal procedures often lead to postoperative pain. Clinicians use pharmacological methods such as anesthetics, anti-inflammatory drugs, and analgesics for relief. However, the multitude of options makes it challenging to select the best approach for routine dental care.

Objective

This review aimed to describe previous studies regarding the pharmacological management used for pain control during periodontal procedures as well as factors that may interfere with patients' perception of pain.

Methods

We included studies (period of 2000-2023, whose approach corresponded to the pharmacological protocols used for preoperative, trans-operative, and postoperative pain control in adult patients undergoing surgical and non-surgical periodontal therapy.

Results

A total of 32 studies were included in the analysis, of which 17 (53%) were related to anesthetic methods and 15 (47%) were related to therapeutic protocols (anti-inflammatory/analgesic agents). These studies predominantly involved nonsurgical periodontal procedures. Studies have reported that factors related to age, type of procedure, and anxiety can influence pain perception; however, only seven of these studies evaluated anxiety.

Conclusions

Numerous methods for pain control can be applied in periodontal therapy, which are accomplished through anesthetic methods and/or therapeutic protocols. Factors such as anxiety, age, and type of procedure are related to pain perception in patients. Thus, it is the responsibility of dentists to evaluate each clinical situation and define the best protocol to follow based on the literature.

Jean K, Gingerich W, Abramo N, Stahl D, Walters C, Artemiou E. The Evaluation of a High-Fidelity Simulation Model and Video Instruction Used to Teach Canine Dental Skills to Pre-Clinical Veterinary Students

In recent years, there has been an increased focus on the teaching of small-animal dentistry to veterinary students in order to address the recognized gap between dental skill training and the expectations of employers regarding the competencies of new graduates in this field. In this study, third-year veterinary students were trained in three canine dental core skills using either a high-fidelity model (Group A) or video instruction (Group B). An objective structured clinical examination was used to assess skill acquisition and questionnaires were distributed in order to assess student confidence and perceptions related to small-animal dentistry practice and related skills before and after the training. All results were compared between the two groups. Group A outperformed Group B in skill acquisition (p < 0.001) and there was greater improvement in skill confidence for Group A than Group B (p < 0.001). There was no statistical difference in perceptions related to small-animal dentistry between the two groups after the training (p ≥ 0.1). Group A rated their training experience more highly than Group B (p < 0.001). Although dental skill acquisition shows greater improvement when training is provided by models rather than video instruction, a blended approach to teaching dental skills is likely to be the best approach to optimizing dental skill acquisition.

Discovery of 4-(1,2,4-Oxadiazol-5-yl)azepan-2-one Derivatives as a New Class of Cannabinoid Type 2 Receptor Agonists for the Treatment of Inflammatory Pain

Selectively targeting the cannabinoid receptor CB2 is an attractive therapeutic strategy for the treatment of inflammatory pain without psychiatric side effects mediated by the cannabinoid receptor CB1. Herein, we report the discovery of 4-(1,2,4-oxadiazol-5-yl)azepan-2-one derivatives as a new class of CB2 agonists. Systematic structure-activity relationship investigations resulted in the identification of the most potent compound 25r. This compound displayed high selectivity for CB2 against CB1 (CB2 EC₅₀ = 21.0 nM, E_max = 87%, CB1 EC₅₀ > 30 μM, ratio CB1/CB2 > 1428) with favorable pharmacokinetic properties. Especially, 25r demonstrated significant efficacy in the analgesic model of rodent inflammatory pain. All the results suggest that compound 25r could serve as a lead compound for treating inflammatory pain and deserves further in-depth studies.

Opioid Prescriptions Prior to Emergency Department Dental Visits: A Comparison of Dental Health Professional Shortage Areas (DPSAs) and Non-DPSAs Using Electronic Health Records

Although prior research has linked dental conditions and opioid prescribing in the U.S., it is not yet known whether the receipt of opioid prescriptions prior to seeking emergency care for dental conditions differs in geographical areas that are underserved by health care professionals (Dental Professional Shortage Areas, DPSAs) compared to other areas. Using Indiana's state-wide electronic health records from January 1, 2016 to October 31, 2020, we examine if patients from DPSAs presenting at the emergency department (ED) for dental conditions are more likely to have received opioid prescriptions in the 30 days prior to their visit, compared to patients from other areas. A higher rate of opioid receipt among DPSA individuals may indicate an association between lower availability of dental professionals and the use of opioids as a coping strategy. We note that our study design has several limitations (such as a lack of data on prescription use after the ED visit) and does not prove causation. We find that individuals experiencing dental condition ED visits in DPSAs are 16% more likely (than those in non-DPSAs) to have filled an opioid prescription in the 30 days prior to the ED visit, after controlling for age, gender, and race/ethnicity. This result is statistically significant at the 1% level. The baseline rate of opioid filling in the 30 days prior to the ED visit is 12% in DPSAs. These correlational results suggest that unmet dental needs might be substantially connected to opioid prescriptions, although further research is needed to establish whether this relationship is causal.

Analysis of Osteoclasts and Root Resorption in Corticotomy-Facilitated Orthodontics with Ibuprofen Administration-An Animal Study

Following corticotomy surgery, patients experience moderate to severe post-operative pain that necessitates prescriptions of analgesics. The prostaglandin inhibitory effect of ibuprofen influences the mobility of teeth during orthodontic treatment. This study aimed to determine how ibuprofen affects histological reactions and dental root resorption during orthodontic tooth movement aided by corticotomy. Forty-two male Wistar rats were divided into three groups by random selection: (1) control group, (2) corticotomy group (CO), and (3) corticotomy with 0.6 mL of 15 mg/kg ibuprofen group (CI). On each buccal and palatal alveolar bone, two decortication points were made. Orthodontic tooth movement was induced on the maxillary first molar for 21 days utilizing a NiTi-closed coil spring with 10 g of force. Hematoxylin and eosin were used to prepare and stain the histological sections. The numbers of osteoclasts on days 0, 7, 14, and 21 were determined, and the root resorption area on days 0 and 21 was measured. Compared to the control group, the osteoclast counts in the CO and CI groups were considerably greater (p < 0.002). No significant differences were observed between the CO and CI groups in the numbers of osteoclasts or the percentages of root resorption (p > 0.05). The amounts of osteoclast activity and root resorption were unaffected by the administration of ibuprofen in corticotomy-facilitated tooth movement.

Analysis of Different Methods of Extracting NSAIDs in Biological Fluid Samples for LC-MS/MS Assays: Scoping Review

The aim of this study was to carry out a systematic investigation and analysis of different drug extraction methods, specifically non-steroidal anti-inflammatory drugs in biological fluid samples, for Liquid Chromatography in Mass Spectrometry assays (LC-MS/MS). A search was carried out in the main databases between 1999 and 2021, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Data were obtained through PubMed, Lilacs, Embase, Scopus, and Web of Science databases using the Boolean operators AND and OR. Studies were pre-selected by title and abstract by two independent reviewers. The selected texts were read in full, and only those that were complete and compatible with the inclusion and exclusion criteria were eligible for this research. A total of 248 references were obtained in the databases. After removing the duplicates and analyzing the titles and abstracts, 79 references were evaluated and passed to the next phase, which comprised the complete reading of the article. A total of 39 publications were eligible for this study. In 52% of the studies, the authors used the liquid–liquid extraction method (LLE), while in 41%, the solid-phase extraction method (SPE) was used. A total of 5% used microextraction methods and 2% used less-conventional techniques. The literature on the main methods used, the LLE and SPE methods, is extensive and consolidated; however, we found other studies that reported modifications of these traditional techniques, which were equally validated for use in LC-MS/MS. From this review, it is concluded that the diversity of techniques, reliability, and practical information about each analytical method used in this study can be adapted to advances in LC-MS/MS techniques; however, more ecological, economic, and sustainable approaches should be explored in the future.

Orofacial antinociceptive effects of perillyl alcohol associated with codeine and its possible modes of action

This study evaluated the orofacial antinociceptive effect of (S)-(-)-perillyl alcohol (PA) associated with codeine (C) and investigated the possible molecular anchorage mechanisms of PA. Mice (n = 5 per group) were treated with PA alone and associated with codeine and assigned to the following groups: 75.0 mg/kg PA; 75.0 mg/kg PA + C 30 mg/kg; PA 37.5 mg/kg + C 15.0 mg/kg; C 30.0 mg/kg; and control. Nociception was induced by formalin, capsaicin, and glutamate, and was quantified based on the duration (in seconds) of face grooming. The possible mechanisms of action were evaluated by molecular docking study. In the formalin test, PA75/C30 presented an effect in the neurogenic (p < 0.0001) and inflammatory (p < 0.005) phases. Mice treated with PA75 (p < 0.0001) and PA75/C30 (p < 0.0005) showed a reduced nociceptive behavior in the capsaicin test. Glutamate-induced nociception also was blocked by PA75 (p < 0.0005) and C30 (p < 0.0005). The molecular anchorage analysis indicated high negative binding energy values for the evaluated receptors, especially glutamate receptors (AMPA -79.57 Kcal/mol, mGLUR6 -71.25, and NMDA -66.33 Kcal/mol). PA associated with codeine showed orofacial antinociceptive activity, with theoretical evidence of interaction with glutamate receptors.

Effectiveness of different socket dressing materials on the postoperative pain following tooth extraction: a randomized control trial

We aimed to prospectively evaluate and compare the effectiveness of Alvogyl and Cutanplast as intra-alveolar dressings for managing pain associated with extraction and incidence of dry socket. All patients who underwent maxillary and mandibular teeth extraction and fulfilled our inclusion and exclusion criteria from Feb 2021 to Oct 2021 were included in our study. Patients who were diagnosed with postoperative pain after tooth extraction were randomly allocated to three groups: Group A (Alvogyl), Group B (Cutanplast), and Group C (placebo). Pain relief and healing of the socket were compared between these groups. The collected data were analyzed using the Chi-square test and Z test of proportionality. Alvogyl was superior to the other medication for providing initial pain relief, and the incidence of dry socket was significantly lower than in the Cutanplast and placebo groups (p<0.05). However, wound healing was statistically non-significant among groups A, B, and C (p>0.05). Alvogyl is still the material of choice in terms of pain relief, wound healing, and low incidence of dry socket. Furthermore, no statistically significant difference was detected between the groups in the biographic information, location, and condition of the extracted tooth, presence of a radiologic pathology, or type of extraction procedure. Moreover, whether it is the first extraction or not, Alvogyl and Cutanpast are comparable in postoperative pain management as intra-alveolar dressing materials.

A Novel Pain Relief Approach for the Treatment of Multiple Dental Caries and Pulpitis

Anxiety and stress toward treatment can hamper treatment completion in patients with dental caries and pulpitis. Therefore, effective management of post-treatment pain is important because poor pain management can lead to patient dissatisfaction. Ultrasound-guided nerve blocks provide good postoperative analgesia in maxillofacial surgeries. These surgeries can be performed under general or local anesthesia without complications. Here, we present the case of a patient with dental phobia who was successfully treated with these techniques. The patient was a 22-year-old woman with a history of manic-depressive illness who presented with 23 decayed teeth. She had previously undergone vital pulp therapy; however, post-treatment pain led to treatment-related stress, and the patient discontinued the dental treatment. She preferred the dental treatment to be completed with as little pain as possible and wanted to avoid a pulpectomy. The patient’s history of heavy use of non-steroidal anti-inflammatory drugs (NSAIDs) made her resistant to NSAIDs. As a result, the analgesic effect of NSAIDs could not be expected. After intravenous midazolam and propofol sedation, an ultrasound-guided inferior alveolar nerve block was performed bilaterally, and 0.375% ropivacaine was used as a local anesthetic. The patient did not complain of post-operative pain, and no post-operative analgesics were required.

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.

Is Intracanal Cryotherapy Effective in Reducing Postoperative Endodontic Pain? An Updated Systematic Review and Meta-Analysis of Randomized Clinical Trials

This research aimed to assess the potency of intracanal cold therapy in diminishing postoperative endodontic pain. PubMed, Scopus, the Cochrane Library, EMBASE, the Web of Science, grey literature, and endodontic journals were used to identify randomized controlled clinical trials evaluating postoperative pain after a final irrigation with a cold irrigant (as an experimental group) and a room temperature irrigant (as a control group). The risk of bias was rated according to the Cochrane Collaboration's tool and the Grading Recommendation Assessment, Development, and Evaluation (GRADE) system was used to estimate the evidence quality. For the meta-analysis, a random effects model was utilized. The qualitative analysis contained 16 studies and the quantitative analysis contained 9 studies. The experimental groups showed a reduction in postoperative pain at 6 h (mean difference (MD) = -1.11; p = 0.0004; I2 = 72%; low quality evidence), 24 h (MD = -1.08; p = 0.003; I2 = 92%; low quality evidence), 48 h (MD = -0.38; p = 0.04; I2 = 81%; low quality evidence), and 72 h (MD = -0.69; p = 0.04; I2 = 90%; low quality evidence). A higher quality of evidence from more clinical trials is needed.

Effect of treatment with resiniferatoxin in an experimental model of pulpal inflammatory in mice

AIM

To evaluate whether treatment with resiniferatoxin (RTX) is capable of lowering the plasma levels of PGE₂ and TNF-α, as well as histopathological parameters in inflammation of pulp tissue in a mouse experimental model.

METHODOLOGY

Ten groups of six BALB/c mice were formed as follows: healthy group (H_C ), healthy group treated with RTX (H_RTX ), two groups with pulp inflammation at 14 and 18 hours (PI₁₄ /PI₁₈ ), six groups with pulpal inflammation plus treatment with Ibuprofen (IBU₁₄ /IBU₁₈ ), dexamethasone (DEX₁₄ /DEX₁₈ ) and resiniferatoxin (RTX₁₄ /RTX₁₈ ) at 14 and 18 hours, respectively. Pulpal inflammation was induced through occlusal exposure of the pulp of the maxillary first molar. The plasma levels of PGE₂ and TNF-α and the histological parameters of the pulp tissue of the H_C and H_RTX groups were evaluated at the time of acquiring the animals. In the other groups, the plasma levels of PGE₂ and TNF-α and the histopathological parameters were evaluated at 14 and 18 hours after pulp damage. Plasma levels of PGE₂ and TNF-α were quantified by ELISA, and the histopathological parameters were evaluated by H/E staining. Statistical significance was determined by one-way analysis of variance (ANOVA) to test for overall differences between group means.

RESULTS

A significant increase (*p < .05) in plasma levels of PGE₂ and TNF-α occurred 14 and 18 hours after pulp damage. In addition, treatment with RTX significantly decreased (*p < .05) the plasma levels of PGE₂ and TNF-α at 14 and 18 hours after pulp damage, as well as the infiltrate of inflammatory cells at 18 hours after pulp damage, similarly to treatment with ibuprofen and dexamethasone.

CONCLUSION

It was possible to detect systemic levels of PGE₂ and TNF-α at 14 and 18 hours after pulp damage. Likewise, treatment with RTX was associated with an anti-inflammatory effect similar to treatment with ibuprofen and dexamethasone. These findings place resiniferatoxin as a therapeutic alternative in the treatment of inflammatory diseases in Dentistry.

Prescriptions of analgesics and anti-inflammatory drugs in municipalities from a Brazilian Southeast state

The objective of this study was to describe dental prescriptions of non-steroidal anti-inflammatory drugs (NSAID), opioids, and analgesics dispensed by the Brazilian National Health System (BNHS, SUS in Portuguese) of a Southeastern state from January to December 2017, and to analyze their association with socioeconomic and oral health care services' characteristics at municipal level. Data were collected from the Brazilian Integrated Pharmaceutical Care Management System. Medicines were grouped according to the Anatomical Therapeutic Chemical Classification System. The total number of Defined Daily Doses (DDD) and DDD per 1,000 inhabitants (inhab.) per year were presented and compared between groups of municipalities. Data analysis used the Classification and Regression Tree model performed with IBM SPSS 25.0. The total number of NSAID, opioids, and analgesics prescriptions was 70,747 and accounted for 354,221.13 DDD. The most frequently prescribed medicine was ibuprofen (n = 24,676; 34.88%). The number of dental practitioners in the BNHS per 1,000 inhab. (p < 0.001), first dental appointment coverage (p = 0.010), oral health teams per 1,000 inhab. (p=0.022), and the proportion of rural population (p = 0.014) were variables positively associated with the number of DDD of NSAID per 1,000 inhab. per year. Bolsa Família program coverage per 1,000 inhab. (p = 0.022) was negatively associated with NSAID prescription. Regarding analgesics, first dental appointment coverage (p=0.002) and Bolsa Família program coverage per 1,000 inhab. (p = 0.012) were positively associated with DDD per 1,000 inhab. per year. In conclusion, dental prescriptions of analgesics and NSAID in the BNHS were associated with socioeconomic and oral health care services' characteristics.

The Safety and Efficacy of Pre- and Post-Medication for Postoperative Endo- dontic Pain: A Systematic Review and Network Meta-analysis

Background:

Postoperative Endodontic Pain is a major concern for dentists and their patients, with pain having been reported to occur in 25%–40% of patients treated. Therefore, the aim of this systematic review and Network Meta-analysis (NMA) was to identify the safety and efficacy of pre- and post-medication for reducing postoperative endodontic pain.

Methods:

A literature search was performed in the SCOPUS, MEDLINE, and ScienceDirect, and Cochrane Central databases until December 2019 with no language restriction. Randomized controlled trials evaluating the efficacy of pre- or post-medications compared with other agents, placebo, or no treatment in adult patients who underwent endodontic surgery for postoperative pain were included. The mean difference of postoperative pain was measured using the Standardized Mean Difference (SMD) with its 95% confidence interval (95% CI).

Results:

This Systematic Review included 62 Articles. Of them, 50 studies were included in the NMA. Among all medications, corticosteroids were ranked as the best treatment for the reduction of postoperative pain at 6 and 12 hours with a significant reduction in postoperative pain scores [SMD= -1.18, 95% CI (-1.51: -0.85)] and [SMD= -1.39, 95% CI (-1.77: -1.02)], respectively. Cyclooxygenase-2 (COX-2) inhibitors were ranked as the best treatment for the reduction of postoperative pain at 8 and 24 hours with a significant reduction in postoperative pain scores [SMD= -2.86, 95% CI (-6.05: -1.66)] and [SMD= -1.27, 95% CI (-2.10: -0.43)], respectively. Non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduced the postoperative pain scores in all durations. For postoperative pain at 6 hours, Indomethacin, Novafen, Naproxen, Prednisolone, Ketorolac, Betamethasone, Dexamethasone, Deflazacort, Rofecoxib, Piroxicam, and Ibuprofen significantly reduced the pain score when compared with a placebo. All of these drugs demonstrated a significant reduction at 12 hours except Ketorolac.

Conclusion:

The current evidence suggests that pre- and post-medication can reduce postoperative pain after nonsurgical root canal treatment. Corticosteroids and COX-2 inhibitors showed significant control of the pain up to 12 hours after administration. However, NSAIDs demonstrated a high efficacy from administration and until two days after treatment. Indomethacin, Novafen, prednisolone, and Naproxen were ranked first in most analyzed durations.

Comparison between isolated and associated with codeine acetaminophen in pain control of acute apical abscess: a randomized clinical trial

OBJECTIVES

The study aimed to compare the acetaminophen administration efficacy or its combination with codeine for pain control in acute apical abscesses cases.

MATERIALS AND METHODS

Thirty-nine patients who sought emergency treatment in the Faculty of Dentistry of the Federal University of Rio Grande do Sul were included, all of them with acute apical abscess diagnosis. These patients were divided into two groups: acetaminophen group-prescription of acetaminophen (1000 mg) and acetaminophen-codeine group-prescription of acetaminophen (1000 mg) + codeine (30 mg), both with oral intake every 6 h for 3 days. The pain scores were recorded by the patients on their own at 6, 12, 24, 48, and 72 h after finishing clinical assistance, by filling a pain evolution journal, containing a visual analogue scale (VAS). Student t test was conducted to investigate different mean ages between groups 1 and 2. A comparison of weight and means of initial pain scores between groups was carried out using the Mann-Whitney U test. Chi-square test was performed to compare gender, affected tooth, education, initial swelling, and frequency of adverse effect between test and control groups. Mann-Whitney U test was applied to compare groups in the same period. Friedman's test was used to compare results from the same group over time.

RESULTS

Both groups showed score reduction over time (P < 0.05). Paracetamol-codeine group showed significant pain score reduction at 48 h registers when compared to baseline and at 6 h scores (P < 0.05). Further, pain scores at 72 h were significantly lower, when compared to the baseline, at 6 h, and at 12 h scores (P < 0.05). Acetaminophen group showed significant pain score reduction observed at 72 h, when compared to the baseline and at 6 h scores (P < 0.05). There were no significant differences in pain score reduction over time between groups (P > 0.05). There was no difference between the groups regarding the frequency of adverse reactions (P > 0.05).

CONCLUSION

Both medications were effective for pain control in acute apical abscess cases. The findings might have inferred in pain control of acute apical abscess associated pain in patients who used an antibiotic drug. External validity of the findings for acute apical abscess cases with no need for an antibiotic prescription is uncertain.

CLINICAL RELEVANCE

This paper suggests acetaminophen 1000 mg can be used for pain control in the treatment of acute apical abscess associated with systemic manifestation.

Effect of calcium hydroxide mixed with lidocaine hydrochloride on postoperative pain in teeth with irreversible pulpitis and symptomatic apical periodontitis: a preliminary randomized controlled prospective clinical trial

OBJECTIVES

To investigate the effect of calcium hydroxide mixed with lidocaine HCl on postoperative spontaneous pain.

MATERIALS AND METHODS

Sixty patients having irreversible pulpitis and symptomatic apical periodontitis with a preoperative spontaneous pain and percussion pain which was more than 50 on a visual analogue scale (100 mm VAS) were included in this study. After the preparation of the root canals, the patients were randomly distributed into two groups according to the calcium hydroxide vehicle, control group (mixed with saline) and calcium hydroxide mixed with lidocaine HCl (n = 30). Postoperative spontaneous pain scores were recorded by a VAS every day for a week. Data were analysed using one-way analysis of variance, chi-squared test and Mann-Whitney U tests (p = 0.05).

RESULTS

The calcium hydroxide mixed with lidocaine HCl group resulted in significantly less pain compared with the calcium hydroxide mixed with saline group during days 1 to 4 (p < 0.05). There were no significant differences between the groups in terms of postoperative percussion pain levels (p > 0.05).

CONCLUSION

Within the limitations of this study, it can be concluded that the calcium hydroxide mixed with lidocaine HCl can be beneficial in reducing postoperative pain in teeth with irreversible pulpitis and symptomatic apical periodontitis.

CLINICAL RELEVANCE

The calcium hydroxide mixed with lidocaine HCl can be beneficial in reducing postoperative pain in teeth with irreversible pulpitis and symptomatic apical periodontitis.

CLINICAL REGISTRATION NUMBER

TCTR20181121003.

Effect of Diclofenac Potassium Premedication on Postendodontic Pain in Mandibular Molars with Symptomatic Irreversible Pulpitis: A Randomized Placebo-Controlled Double-Blind Trial

INTRODUCTION

The aim of this prospective, randomized, double-blind clinical trial was to evaluate the effect of a preoperative, single, oral dose of diclofenac potassium (DFK) on postoperative pain and rescue analgesic intake in patients with symptomatic irreversible pulpitis in mandibular molars treated in 1 visit.

METHODS

Seventy emergency patients with moderate to severe preoperative pain randomly received either 50 mg DFK or placebo tablets 1 hour before starting endodontic treatment (n = 35 per group). Patients recorded their pain level 6, 12, 24, and 48 hours after treatment on a 170-mm Heft-Parker visual analog scale. The incidence of rescue analgesic intake was also recorded. Outcome data were statistically analyzed using Mann-Whitney U, Friedman, Wilcoxon signed rank, and chi-square tests. Binary logistic regression assessed the association of predisposing factors with postoperative pain. The significance level (α) was set at 0.05.

RESULTS

Of the 70 patients, 68 were analyzed (n = 34 per group). Both groups had similar baseline characteristics (P > .05). DFK showed significantly less pain incidence and intensity than the placebo at 48 hours only (P < .05). A significant decrease occurred from 24 to 48 hours with DFK (P < .05), which was not recorded with the placebo (P > .05). No difference in the incidence of rescue analgesic intake was reported between groups (P > .05). Food intake timing, sex, and rescue analgesic intake were associated with postoperative pain (P < .05).

CONCLUSIONS

Premedication by a single, oral dose of 50 mg DFK could be effective in reducing postendodontic pain at 48 hours after 1-visit endodontic treatment in mandibular molars with symptomatic irreversible pulpitis.

Managing Acute Dental Pain: Principles for Rational Prescribing and Alternatives to Opioid Therapy

Pharmacotherapy forms an integral part of acute dental pain management. In a majority of cases, safe and effective management of acute dental pain can be accomplished with a non-opioid medication regimen. Nonetheless, in certain circumstances use of opioid medications may be needed. Furthermore, there are various pain management regimens, such as pre-emptive analgesia, post-procedural cold compression, use of long acting anesthetic, and compound drug therapy that can improve the efficacy of analgesics to achieve a desired therapeutic response without compromising patient safety.

Self-diagnosis & pain management in dental students in Riyadh, KSA

Introduction

Self-diagnosis and pain management is a worldwide practice. The current study aims to determine the percentage of dental students and interns who self-diagnose and manage their dental pain and further establish the proportion of students who depend on various resources for diagnosing and treating their condition.

Methods

A cross-sectional, self-administered questionnaire-based study was conducted among the dental students in and around Riyadh. The questionnaire consisted of three parts including: part 1-demographic data; part 2-pain and self-diagnosis; part 3-visiting the dentist and managing the pain. The data were analyzed using the Statistical Package for Social Sciences (SPSS version 22.0).

Results

Fifty four percent of the participants were involved in self-diagnosis and managed the pain by themselves. Seventy three percent of the respondents experienced teeth/gum discomfort or any symptoms of an oral health problem, of which 57% searched the symptoms they faced on the internet to arrive at a diagnosis. Besides, 35% of the interns considered internet to be a helpful tool for diagnosing their pain. 16% admitted that they have never visited a dentist.

Conclusion

We found that a significant proportion of the participants self-diagnosed by using their background or resorting to the internet, at times consulting a dentist to confirm their diagnosis. The students from the health sciences background should refrain from this practice. Efforts should be made to make the population mindful of the potential risks linked to self-medication and diagnosis. Further research should be done with a larger sample size by including the students and interns from different institutions.

Potential Novel Strategies for the Treatment of Dental Pulp-Derived Pain: Pharmacological Approaches and Beyond

The diagnosis and management of pain is an everyday occurrence in dentistry, and its effective control is essential to ensure the wellbeing of patients. Most tooth-associated pain originates from the dental pulp, a highly vascularized and innervated tissue, which is encased within mineralized dentin. It plays a crucial role in the sensing of stimuli from the local environment, such as infections (i.e. dental caries) and traumatic injury, leading to a local inflammatory response and subsequently to an increase in intra-pulp pressure, activating nerve endings. However, thermal, chemical, and mechanical stimuli also have the ability to generate dental pulp pain, which presents mechanisms highly specific to this tissue and which have to be considered in pain management. Traditionally, the management of dental pulp pain has mostly been pharmacological, using non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, or restorative (i.e. removal of dental caries), or a combination of both. Both research areas continuously present novel and creative approaches. This includes the modulation of thermo-sensitive transient receptor potential cation channels (TRP) by newly designed drugs in pharmacological research, as well as the use of novel biomaterials, stem cells, exosomes and physical stimulation to obtain pulp regeneration in regenerative medicine. Therefore, the aim of this review is to present an up-to-date account of causes underlying dental pain, novel treatments involving the control of pain and inflammation and the induction of pulp regeneration, as well as insights in pain in dentistry from the physiological, pharmacological, regenerative and clinical perspectives.

Attitude and Awareness of Dentists Practicing in Southern India Toward Non-steroidal Anti-inflammatory Drugs

Background:

Pain management is an everyday challenge in dentistry. Analgesics are the group of drugs prescribed for effective pain management, of which nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed drugs. Selection of NSAIDs must be judiciously made considering their pharmacological properties and adverse effects.

Aim:

This study aimed to analyze the attitude toward analgesic prescription among practicing dentists and the awareness to update their knowledge about them.

Materials and Methods:

The study was carried out among 100 dental practitioners, where a questionnaire consisting of 16 questions was formulated based on the awareness of indication and contraindication, actual practice, and required future trends for updating the knowledge. The questionnaire was distributed among the practitioners; the answered questionnaire was collected and tabulated. Statistical analysis included χ² test to evaluate the significance.

Results:

Of 100 dental practitioners, 63% prescribed drugs based on the diagnosis. Aceclofenac was found to be the effective drug in postoperative pain management, whereas paracetamol was considered to be the safest among NSAIDs in clinical conditions such as bleeding disorders, gastric irritation, chronic kidney disease, and during pregnancy. All practicing dentists showed their willingness to participate in awareness programs in updating their knowledge.

Conclusion:

This study showed that dental clinical practitioners are well aware of the drugs to be prescribed in different clinical conditions but pitfalls have been observed in areas of systemic complication, where continuous educational programs are needed to overcome the same.

Effect of pretreatment medication on postendodontic pain: A double-blind, placebo-controlled study

BACKGROUND

Posttreatment endodontic pain has been reported in 25%-40% of all endodontic patients. Effective management of endodontic pain represents a continuing challenge.

AIM

To evaluate and compare the efficacy of preoperative single dose of nonsteroidal anti-inflammatory drug, piroxicam (20 mg), with two types of corticosteroid drugs - dexamethasone (4 mg) or deflazacort (30 mg) - for the prevention and control of postendodontic pain.

MATERIALS AND METHODS

A total of 132 volunteers selected for nonsurgical root canal therapy were randomly divided into the following four groups (n = 30 each) according to preoperative medication given: Group 1, piroxicam (20 mg); Group 2, dexamethasone (4 mg); Group 3, deflazacort (30 mg); and Group 4, placebo. The preoperative medications were administrated 1 h before the start of standard endodontic treatment. Patients were instructed to complete a pain diary using Visual Analog Scale preoperatively and at 6-, 12-, 24-, 48-, and 72-h intervals after root canal instrumentation.

STATISTICAL ANALYSIS

The correlation between preoperative endodontic pain to postoperative pain and pair-wise comparison of four groups was evaluated by Kruskal-Wallis analysis of variance test followed by Mann-Whitney U-test.

RESULTS

Compared to the placebo group, piroxicam, dexamethasone, and deflazacort resulted in a statistically significant reduction in postendodontic pain at 6, 12, and 24 h (P < 0.05).

CONCLUSION

Preoperative single oral dose of piroxicam or dexamethasone or deflazacort is equally effective in controlling postendodontic pain.

Effects of Ibuprofen Compared to Other Premedication Drugs on the Risk and Intensity of Postendodontic Pain: A Systematic Review

Objective

This systematic review aims to evaluate the effects of ibuprofen compared to other drugs on the risk and intensity of postoperative pain resulting from endodontic treatment in adult patients.

Methods

A systematic search was carried out through Medline databases (Pubmed, Scopus, Web of Science, Cochrane, Lilacs, and BBO). There was no restriction on the publication year or idiom. The gray literature was explored. The Periodicos Capes Theses Databases and ProQuest Dissertations were also searched, as well as the unpublished and ongoing trials registry and the IADR abstracts (1990-2016). Solely randomized clinical trials that compared the risk or intensity of pain resulting from endodontic treatment in adult patients were included in this systematic review. The risk of bias of the articles was evaluated using the Cochrane Collaboration's tool. A random-effect meta-analysis was conducted for ibuprofen versus placebo and ibuprofen versus other drugs at 6, 8, and 24 hours. The GRADE approach was used to assess the quality of the evidence.

Results

A total of 1132 studies were identified, and only seven meet the eligibility criteria. No difference between the groups was detected in any of the meta-analysis. An exception was observed when one study was removed from the meta-analysis of pain intensity at 24 hours for ibuprofen versus placebo, favoring ibuprofen (SMD -0.67; 95% CI -1.05 to -0.17). The quality of evidence in all meta-analyses was graded as low or very low.

Conclusion

Results of the present systematic review indicate that there is no clear evidence supporting that preoperative ibuprofen is better than other drugs in reducing the risk and intensity of postendodontic pain.

Association between beliefs about medicines and self-medication with analgesics among patients with dental pain

Self-medication with analgesics in dental pain management is a common practice as most of these medicines are available over-the-counter (OTC). The study aims to examine the relationship between beliefs about medicines and self-medication with analgesics in dental pain management in Malaysia. This cross-sectional study was conducted among conveniently sampled patients attending dental clinics, located in Kuala Lumpur, Malaysia to assess association between self-medication with analgesics and patient's beliefs about medicines via Beliefs about Medicines Questionnaire. Participants were evaluated for their self-medication practices via 4 items. Further assessment was done via Quantitative Analgesic Questionnaire (QAQ) regarding the analgesics taken. Statistical analyses were performed using SPSS version 24, with 0.05 as level of significance. The prevalence of self-medication with analgesics was 29.4%, with 95.6% of the participants took analgesics when necessary. Participants practising self-medication for dental pain reported more positive beliefs in General-Necessity (13.04 vs. 9.98, p = 0.001) than those not practising self-medication. However, these participants had weaker beliefs in General-Harm (12.00 vs. 10.29, p = 0.006) and General-Overuse (11.38 vs. 10.31, p = 0.032) than those not practising self-medication. Participants beliefs in General-Harm (r = -0.243; p = 0.003) and General-Overuse (r = -0.203; p = 0.012) were negatively correlated with total QAQ point. The study found that individuals who practised self-medication had stronger beliefs about the benefits of medicines and weaker beliefs in viewing medicines as harmful and overused. Findings can guide public education to improve the safety aspects of self-medication with analgesics in dental practice.

Interim therapeutic restoration approach versus treatment under general anaesthesia approach

BACKGROUND

Although dental treatment under general anaesthesia (GA) remains the long-established approach for treating anxious children, treatment under GA presents with increased risks, costs and parental acceptability issues. Interim therapeutic restoration (ITR) has been proposed as an alternative approach.

AIM

To compare the incidence and types of failures between children managed with the ITR approach and those managed under GA within 12 months of treatment completion.

DESIGN

A retrospective cohort study of children who received dental treatment utilizing the ITR approach was compared to children treated under GA. Age, gender and dental disease matching was done. Statistical analyses were carried out with Independent t-test and chi-square analyses.

RESULTS

A total of 132 children (GA = 66, ITR = 66) were included, and the groups did not differ in terms of initial age, sex, dmft and initial behaviour score. ITR group had a significantly higher rate (P < 0.001; 95% CI: [0.21 to 0.97]) of restorative failure and visits required when compared to the GA group. There were no difference for incidence of pain (P = 0.55; 95% CI: [-0.074 to 0.10]) and behaviour scores (P = 0.46) between the two groups at the 12-month visit.

CONCLUSIONS

ITR approach may be a viable alternative to the GA approach when treating paediatric dental patients.

Comparison of Acupuncture with Ibuprofen for Pain Management in Patients with Symptomatic Irreversible Pulpitis: A Randomized Double-Blind Clinical Trial

Emergency pain management in symptomatic irreversible pulpitis commonly includes use of nonnarcotic analgesics. Acupuncture has been used in dentistry to alleviate pain after tooth extraction. The aim of this randomized, double-blind, placebo controlled clinical trial was to evaluate and compare the efficacy of acupuncture therapy and ibuprofen for pain management in such patients. A total of 157 patients participated in this study and were randomly assigned to three groups, Group I-classical acupuncture with placebo tablet, Group II-sham acupuncture with placebo tablet, and Group III-sham acupuncture with ibuprofen. Before commencement of the experiment, initial pain assessment was done using a HP-VAS scale. Treatment was done by first operator, while pain assessment was done by the second operator who was blinded to the procedure performed. Acupuncture needles were inserted for 15-20 minutes at acupoints for classical acupuncture and at nonacupoints for sham acupuncture. Posttreatment pain assessment was carried out at 15, 30, 45, and 60 minutes intervals. Follow-up analysis was recorded at 12, 24, and 48 hours using VAS verbal scale. The mean final HP VAS values for Group I showed statistically significant lower pain values when compared with groups II and III (p < 0.05), with no significant difference between groups II and III. Follow-up analysis showed Group I with higher percentage of no pain, which was statistically significant when compared with other two groups. It can be concluded that classical acupuncture is more effective in pain relief (faster and prolonged) than analgesics.

Clinical guideline for the management of odontogenic infections in the tertiary setting

BACKGROUND

Odontogenic infections are a common presentation to emergency departments of Australian hospitals. Due to the limited training in diagnosis and treatment of dental conditions, these patients can present a challenge for the medical practitioner. The objective of this study was to provide an evidence-based approach to the management of odontogenic infections in adults presenting to Royal Perth Hospital.

METHODS

A literature search was conducted to identify evidence-based guidelines for the management of odontogenic infections in the tertiary hospital setting. Keywords 'dental', 'infections' and 'management' were used to search PubMed, DynaMed and Embase databases.

RESULTS

Recommendations were drawn from existing literature including coroner reports with respect to clinical assessment, investigations, medical and surgical management, and postoperative care. A flow chart, incorporating these recommendations, was created to allow for appropriate disposition of patients presenting with odontogenic infections to Royal Perth Hospital.

CONCLUSIONS

A clinical guideline is needed to appropriately manage patients presenting with odontogenic infections. We recommend the guideline be submitted to intradepartmental committees for assessment.

The effect of preoperative oral administration of prednisolone on postoperative pain in patients with symptomatic irreversible pulpitis: a single-centre randomized controlled trial

AIM

This single-centre randomized, double-blind, placebo-controlled clinical trial assessed the effect of a preoperative, single, oral dose of prednisolone on postoperative pain and postoperative analgesic intake in patients with symptomatic, irreversible pulpitis in mandibular molars.

METHODOLOGY

Four hundred participants, randomly assigned to two equal groups, received either 40 mg prednisolone or placebo tablets 30 min before single-visit root canal treatment. Patients recorded their pain level 6, 12 and 24 h after treatment on a 100-mm visual analogue scale. All patients received a sham capsule to take if needed as a postoperative analgesic, and, if the pain persisted, an analgesic was prescribed. The relative risk reduction and 95% confidence intervals (CI) were estimated for binary data. Mann-Whitney U-test was used to compare postoperative pain intensity between groups.

RESULTS

The relative risk reduction in pain incidence was 20.31% (95% CI: 12.03%, 27.82%) at 6 h, 23.39% (95% CI: 14.75%, 31.16%) at 12 h and 28.85% (95% CI: 18.08%, 38.20%) at 24 h. Prednisolone had significantly less post-obturation pain intensity compared to placebo at 6, 12 and 24 h (P < 0.001). The relative risk reduction in sham-capsule intake was 54% (95% CI: 38%, 66%) and of analgesic intake was 55% (95% CI: 3%, 79%). No adverse effects were recorded.

CONCLUSION

Preoperative oral administration of a single dose of 40 mg prednisolone was beneficial to control short-term post-obturation pain after single-visit root canal treatment in patients with symptomatic irreversible pulpitis reducing pain incidence after 24 h by approximately 30% and postoperative analgesic intake by approximately 55%.

Predictors, prevention, and management of postoperative pain associated with nonsurgical root canal treatment: A systematic review

Postoperative pain after root canal treatment can be reduced by applying recent advances in endodontic techniques and equipment. This systematic review includes current knowledge about pain after nonsurgical root canal treatment, including predictors, related factors, effects of recent advances, and management. A literature search was performed using the PubMed, ScienceDirect, and Cochrane Library databases for articles published between 1990 and 2016. Search keywords included postoperative pain, nonsurgical treatment, single visit, recent advances in endodontics, and management of postoperative pain with endodontic treatment. Only original research studies were included; editorials, reviews, brief notes, conference proceedings, and letters to the editor were excluded. The initial search yielded 4941 articles, which were assessed and filtered using the selection criteria. Sixty-five studies met the inclusion criteria and were included in the review. The findings showed that pain after nonsurgical root canal treatment occurred in 3–69.3% of patients. Microorganisms were identified as the primary contributors to postoperative pain, and there was no significant difference in postoperative pain between single- and multiple-visit treatments. Postoperative pain after root canal treatment ranges from mild to moderate and occurs even after optimally performed procedures. Furthermore, adequate management of postoperative pain is often considered an indicator of clinical excellence. Application of recently developed endodontic techniques and devices will reduce postoperative pain. Furthermore, a flexible, severity-based drug administration plan can be used to control and manage pain after root canal treatment. Application of the current research findings will reduce pain following root canal treatment and improve patient outcomes.

Selective 5-HT7 receptor agonists LP 44 and LP 211 elicit an analgesic effect on formalin-induced orofacial pain in mice

The most recently identified serotonin (5-HT) receptor is the 5-HT7 receptor. The antinociceptive effects of a 5-HT7 receptor agonist have been shown in neuropathic and inflammatory animal models of pain. A recent study demonstrated the functional expression of 5-HT7 receptors in the substantia gelatinosa (SG) of the trigeminal subnucleus caudalis, which receives and processes orofacial nociceptive inputs.

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.

Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments

BACKGROUND

Opioid analgesics prescribed for nontraumatic dental conditions (NTDCs) by emergency physicians continue to receive attention because of the associated potential for misuse, abuse and addiction. This study examined rates of prescription of opioid analgesics and types of opioid analgesics prescribed for NTDC visits in U.S. emergency departments.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey from 2007 to 2010 were analyzed. Descriptive statistics and logistic regression analysis were performed and adjusted for the survey design.

RESULTS

NTDCs made up 1.7% of all ED visits from 2007 to 2010. The prescription of opioid analgesics was 50.3% for NTDC and 14.8% for non-NTDC visits. The overall rate of opioid analgesics prescribed for NTDCs remained fairly stable from 2007 through 2010. Prescription of opioids was highest among patients aged 19-33 years (56.8%), self-paying (57.1%), and non-Hispanic Whites (53.2%). The probability of being prescribed hydrocodone was highest among uninsured patients (68.7%) and for oxycodone, it was highest among private insurance patients (33.6%). Compared to 34-52 year olds, children 0-4 years were significantly more likely to be prescribed codeine and less likely to be prescribed oxycodone. Compared to non-Hispanic Whites, non-Hispanic Blacks had significantly higher odds of been prescribed codeine and somewhat lower odds of been prescribed oxycodone, but it was not statistically significant.

CONCLUSIONS

There was no significant change in the rates of opioid analgesics prescribed over time for NTDC visits to EDs. Age, payer type and race/ethnicity were significant predictors for the prescription of different opioid analgesics by emergency physicians for NTDC visits.

Glial network responses to polymicrobial invasion of dentin

This study investigated the distribution patterns of glial networks disclosed by reactivity for glial fibrillary acidic protein (GFAP) and S100B in healthy and carious human teeth. The objective was to determine the assembly and collapse of glial networks in response to encroaching infection. 15 healthy and 37 carious posterior teeth from adults were studied. Immediately after extraction, teeth were cleaned and vertically split and the half with pulp fixed and prepared for resin or frozen sections. Sections were stained with toluidine blue and for immunofluorescence, with observation by confocal laser microscopy and analysis by ImageJ software. Carious teeth were subdivided into three groups according to degree of carious involvement: microbial penetration through enamel (stage A), extension into dentin (stage B) and advanced penetration into dentin but without invasion of underlying pulp tissue (stage C). In stage A lesions there was marked increase in glial networks in dental pulp tissue that extended beyond the zone of microbial invasion. This response was maintained in stage B lesions. In advanced stage C lesions these networks were degraded in the zone of invasion in association with failure to contain infection. Cells expressing the glial markers GFAP and S100B showed a response to initial microbial invasion of dentin by increase in number and altered anatomical arrangement. The late stage of dentinal caries was marked by collapse of these networks in the region adjacent to advancing bacteria. This behaviour is important for understanding and explaining the defensive response of the neurosensory peripheral dental pulp apparatus to infection.

Acupuncture in the management of acute dental pain

Acute dental pain is the main reason for seeking dental services to provide urgent dental care; there is consensus about the use of alternative therapies, such as acupuncture, to control dental pain in pre-dental care. This study aimed to evaluate the use of acupuncture in reducing the intensity of acute dental pain in pre-dental care in patients waiting for emergency dental care, and was conducted at the After-Hours Emergency Dental Clinic of Piracicaba Dental School, and at the Emergency Center Dental Specialties I in Piracicaba, São Paulo, Brazil. The sample consisted of 120 patients. The Visual Analog Scale (VAS) was used to measure pain intensity. All patients underwent one session of acupuncture; the points LI4, ST44 and CV23 were selected and were used alone or in combinations. Reduction in pain was observed in 120 patients (mean initial VAS=6.558±1.886, p<0; mean final VAS=0.962±2.163, p<0.00001). The results of this study indicate that acupuncture analgesia could be a technical adjunct to pain control in patients with acute dental pain, contributing to the restoration of health with social benefit.

Conventional medical attitudes to using a traditional medicine vodou-based model of pain management: survey of French dentists and the proposal of a pain model to facilitate integration

OBJECTIVES

The purposes of this study were to develop a pain management model using traditional medicine (TM) vodou healing methods; to survey a sample of French dentists to rate components of conventional and proposed TM vodou-based pain management model; and to assess the possibility of conventional, allopathic providers to integrate TM or complementary and alternative medicine concepts.

METHODS

From a set of 30 fact sheets collected from TM African healers (vodou healers), main clinical concepts and terminology were extracted. Twenty vodou-based pain management concepts were collected from an interview with a TM vodou practitioner. From this information, a 7-step vodou-based pain management model was created. A sample of 40 French dentists from Nantes, France, whose practices focused on the clinical treatment of dental pain, was surveyed to assess the importance of both TM (vodou) and conventional biomedical components.

RESULTS

Seventy percent of the dentists sampled rated the rational components of the TM model as "very important" or "important" for pain treatment, whereas 2 other traditional concepts were considered to be "supernatural" or beyond understanding.

CONCLUSION

This study showed that traditional healers used conventional concepts and conventional practitioners could use traditional concepts. This suggests that conventional allopathic medical providers have the capacity to integrate biomedical concepts and other therapeutic and explanatory models. This information may be helpful to understand and improve risk management by anticipating and preventing potential reasons for failure in TM integration strategies and to enhance communication between patients, healers, and physicians to optimize TM or complementary and alternative medicine integration.