Postoperative pain after root canal treatment: a prospective cohort study

Efficacy of preoperative and postoperative medications in reducing pain after non-surgical root canal treatment: an umbrella review

OBJECTIVE

This study analyzed, using an umbrella review, existing systematic reviews on medications to prevent and control postoperative endodontic pain to guide professionals in choosing the most effective drug.

MATERIALS AND METHODS

An electronic search in the PubMed (MEDLINE), LILACS, SciELO, EMBASE, Scopus, Web of Science, Cochrane Reviews, and Data Archiving and Networked Services (DANS) databases retrieved 17 systematic reviews. The study included only systematic reviews of clinical trials with or without meta-analyses evaluating effectiveness of medications in reducing pain after non-surgical endodontic treatment.

RESULTS

The evidence showed that steroidal and non-steroidal anti-inflammatory drugs and opioids effectively controlled pain within six to 24 h.

CONCLUSIONS

Dexamethasone, prednisolone, paracetamol, and mainly ibuprofen provided higher postoperative pain relief. The quality of evidence of the reviews ranged from very low to high, and the risk of bias from low to high, suggesting the need for well-designed clinical trials to provide confirmatory evidence.

CLINICAL RELEVANCE

This review emphasizes the efficacy of developing protocols for pain control after endodontic therapy.

Postoperative pain in oncological patients subjected to nonsurgical root canal treatment: a prospective case-control study

OBJECTIVES

The purpose of this prospective study was to evaluate the incidence and intensity of postoperative pain in oncological patients with infected teeth subjected to nonsurgical root canal treatment or retreatment.

METHODS

Teeth with apical periodontitis from healthy control patients and oncological patients (n = 70 per group) were root canal treated/retreated and evaluated for the development of postoperative pain. Patients from the two groups were matched for tooth type, gender, clinical manifestation of apical periodontitis, and intervention type. A visual analogue scale (VSA) was used to evaluate the incidence of postoperative pain at 24 h, 72 h, 7d, and 15d after chemomechanical procedures. Data were statistically analyzed for the incidence and intensity of postoperative pain in the two groups.

RESULTS

Preoperative pain occurred in 10% of the individuals and in all these cases pain showed a reduction in intensity or was absent after endodontic intervention at 24-h evaluation. The overall incidence of postoperative pain at 24 h was 14% in oncology patients and 30% in controls (p = 0.03). At 72 h, the respective corresponding figures were 4% and 8.5% (p > 0.05). At 7 and 15 days, all patients were asymptomatic, irrespective of the group.

CONCLUSIONS

No significant differences in postoperative pain were found between control and oncological patients. The low incidence of postoperative pain observed in both groups supports the routine use of nonsurgical root canal treatment/retreatment as valid options in oncological patients.

CLINICAL RELEVANCE

Oncological patients had no increased risk of postoperative pain in comparison with control patients.

Post-operative pain after root canal preparation with different apical finishing sizes a triple blinded split mouth clinical trial

BACKGROUND

This is a triple-blinded, prospective split-mouth clinical trial. It is important to shed light on the effect of different apical preparation sizes regarding postoperative pain within the same patient with the same pulpal histological status. The aim is to compare and evaluate the severity of postoperative pain following apical enlargement with two different sizes after the IBF using the visual analogue scale.

METHODS

Fifty "teeth" in 25 patients were assigned into two equal groups (25 per group) using E3 Azure rotary files; Group A was prepared two sizes greater than the Initial binding file (IBF) (the largest K file to bind at the actual working length) mesial canals, which were enlarged to 35#/0.04 and 40#/0.04 for the distal canals. Group B was prepared in three sizes larger than the IBF: 40#/0.04 for mesial canals and 45#/0.04 for the distal canals. On a modified VAS form, patients were questioned to indicate the degree of their pain and assisted in narrating their pain intensity during the following periods: 12, 24, and 72 h, and after a week. VAS data were non-parametric and analyzed using the signed-rank test for intergroup comparisons, Freidman's test, and the Nemenyi post hoc test for intragroup comparisons. The significance level was set at p < 0.05.

RESULTS

showed that regardless of measurement time, enlargement of apical preparation was significantly associated with higher pain scores (p < 0.001). Within both groups, there was a significant reduction of measured pain score with time, with values measured after 12 and 24 h being significantly higher than values measured at other intervals (p < 0.001) and with values measured after three days being significantly higher than 1-week value (p < 0.001).

CONCLUSION

The size of apical preparation had a significant effect on postoperative pain.

TRIAL REGISTRATION NUMBER & DATE

NCT05847738, 08/05/2023.

Impact of Cryotreated and Warm Sodium Hypochlorite on Postoperative Pain in Teeth With Symptomatic Irreversible Pulpitis: A Randomized Controlled Trial

INTRODUCTION

The purpose of this study was to evaluate effect of cryotreated and warm sodium hypochlorite (NaOCl) on postoperative pain in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.

METHODS

Sixty-six individuals with preoperative pain scores of ≥54 mm on the Heft Parker Visual Analogue Pain Scale (HP-VAS) diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis as per the American Association of Endodontists guidelines in mandibular molars were included. The preparation of the access and the root canals was instrumented and irrigated in accordance with a standard protocol. Based on the temperature of the final irrigant, the root canals were then randomly assigned to 3 groups and 3% NaOCl was irrigated: control (at 25°C), cold NaOCl (2°C), and warm NaOCl (60°C) (n = 22/group). Root canal treatment was completed at the same visit. Pre- and postoperative pain assessment at 6, 24, 48, and 72 hours was conducted using the HP-VAS, and analgesic consumption was noted. Suitable statistical tests were used to analyze the data.

RESULTS

In comparison with the other 2 groups, the cold NaOCl group had a lower HP-VAS score at all follow-up intervals. Between groups, there was a statistically significant difference in postoperative pain scores at 6 and 72 hours (P < .05). None of the subjects experienced any postoperative discomfort at 72 hours in the control and cold NaOCl groups.

CONCLUSION

Patients treated with cold NaOCl as the final irrigant experienced significantly less postoperative pain at 6 hours when compared with room temperature and warm NaOCl.

Pain, anxiety, and catastrophizing among pregnant women with dental pain, undergoing root canal treatment

This prospective study aims to evaluate dental pain, anxiety, and catastrophizing levels in pregnant women undergoing root canal treatment. Sixty pregnant and non-pregnant women presenting dental pain and an indication for root canal treatment were included in the study. Dental anxiety and catastrophizing were investigated using validated questionnaires. The endodontic intervention was performed, and a numerical scale measured preoperative and postoperative dental pain. The results were analyzed using STATA software 12.0. Unadjusted analyses assessed the association between pregnancy and pain, anxiety, and catastrophizing levels. Multiple linear regression models using 'forward stepwise' entry procedures were used to assess the independent effects of variables on pain scores. The significance level was set at 0.05. Initially, most patients experienced intense dental pain. The levels of dental pain, dental anxiety, and catastrophizing did not differ between pregnant and non-pregnant women. Logistic regression showed that postoperative pain was associated with irreversible pulpitis diagnosis (OR = 4.78; 95%CI 1.55-13.55) and high catastrophizing levels (OR = 1.96; 95%CI 1.01-3.84). Preoperative and postoperative pain rates and anxiety and catastrophizing were similar between pregnant and non-pregnant patients. Postoperative pain was associated with irreversible pulpitis diagnosis and high catastrophizing levels. The similarity between pregnant and non-pregnant women regarding preoperative and postoperative dental pain and catastrophizing and anxiety levels supports the indication of root canal treatment during the gestational period whenever necessary.

Post-operative pain after single-visit root canal treatment using resin-based and bioceramic sealers in teeth with apical periodontitis: A randomised controlled-trial

The present study aimed to compare postoperative pain in teeth with symptomatic and asymptomatic apical periodontitis (AP) following a single-visit endodontic treatment using BioRoot™ RCS or AH Plus at 8 h, 24 h and 48 h postoperatively. Postgraduate students performed endodontic treatment on 101 teeth with AP, randomised into two obturation groups. A 100-mm Visual Analog Scale was used to document the intensity of pain at preoperative, 8-h, 24-h and 48-h intervals. The Kolmogorov-Smirnov test was used for normality, and the median and interquartile ranges were compared using the Mann-Whitney U test. Preoperative pain (1.90 ± 3.50) was more frequent in teeth with symptomatic AP (p < 0.05). However, no significant differences were observed in postoperative pain at the 8-h, 24-h and 48-h intervals. Pre and postoperative pain were directly associated (p < 0.05). Single-visit root canal treatment in teeth with AP using both sealers resulted in similar levels of postoperative pain.

The effect of apical patency on postoperative pain following endodontic therapy: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to determine whether apical patency increases postoperative pain after endodontic therapy. This study explored the degree and incidence of postoperative pain during root canal therapy, as well as the number of required analgesic doses. We searched PubMed, Scopus, Embase, Web of Science, Cochrane Library, and gray literature from the date of database inception until May 2023. RevMan 5.4 software was used for data analysis. Twelve studies were considered eligible for meta-analysis. The mean pain scores on days 1 (mean difference [MD] = -1.69) and 2 (MD = -0.85) differed significantly between the apical patency and non-patency groups. The odds for pain after 24 h were significantly lower (OR 0.59) in the apical patency group than in the non-patency group. Furthermore, the mean number of required analgesic doses was not significantly different between the two groups. In conclusion, apical patency significantly alleviated postoperative pain (low-quality evidence) and reduced the incidence of pain (moderate evidence). However, high-quality randomized controlled trials are required to validate these findings.

The influence of laser-activated irrigation on post-operative pain following root canal treatment: A systematic review

OBJECTIVES

Synthesise evidence on post-endodontic pain (PEP) in adult teeth undergoing primary root canal treatment with the adjunctive use of laser-activated irrigation (LAI) as compared with conventional needle irrigation (CNI) during the first post-operative week.

DATA

An electronic search was performed; no language constraints or restriction on the year of publication were applied.

SOURCES

Medline, Scopus, Cochrane and PubMed on 04 June 2023 STUDY SELECTION: Randomised clinical trials (RaCTs) that evaluated PEP after LAI of endodontic irrgants were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. PEP was analysed at various time intervals until 1 week after treatment, related to the type of LAI used and the need for analgesia.

REULTS

Of the 793 articles identified through the electronic database search, 6 RaCTs were included. Qualitative review was favoured over meta-analysis due to substantial methodological heterogeneity between studies. Five studies were at high risk for bias determined by the Cochrane Risk-of-Bias 2 tool. Diode LAI demonstrated superior efficacy to needle irrigation in reducing pain 6-48 h post-treatment. The impact of LAI by photon-induced photoacoustic streaming (PIPS) was unclear and no difference was observed between PIPS and needle irrigation. However, PIPS mitigated PEP better than manual dynamic activation, sonic and ultrasonic activation. There was no difference in analgesia intake between LAI and needle irrigation groups.

CONCLUSIONS

LAI may help reduce PEP in the first 48 h. Methodological standardisation of future RaCTs on LAI would be beneficial in allowing a more accurate review with the possibility of quantitative synthesis.

CLINICAL SIGNIFICANCE

This unique synthesis used stringent criteria to reduce confounding factors and provided valuable evidence regarding PEP with different types of LAI. It helps clinicians choose an appropriate LAI technique as compared with CNI and predicts a time frame for reducing PEP.

A systematic review and meta-analysis on the effects of phototherapy on postoperative pain in conventional endodontic reintervention

OBJECTIVES

This systematic review and meta-analysis (SRM) aimed to evaluate the efficacy of laser phototherapy (LPT) on the reduction in postoperative pain (PP) of endodontic origin after conventional/non-surgical reintervention of root canals.

METHODS

This SRM was registered with PROSPERO (CRD42021243500) and followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Meta-analysis was conducted using R software with the "META" package, the mean difference (MD) measure of effect was calculated, and the fixed effect model was applied with a 95% confidence interval (CI). The Cochrane collaboration scale was used to assess the risk of bias and the GRADE tool to assess the quality of evidence.

RESULTS

Initially, 1028 articles were found, and five articles were included. Most studies were classified as "low" risk of bias. Of the five clinical studies, four showed a significant decrease in PP after endodontic reintervention in the LPT groups compared to the control group, especially in the first four days after the intervention. In symptomatic teeth with multiple roots, LPT led to less PP at 24 h (MD -0.52 [-1.03; -0.02] p = .04). However, no significant difference between the groups was found at 48 and 72 h (p > .05). The certainty of the evidence was classified as low.

CONCLUSION

Despite the limitations of this SRM, LPT was shown to be a promising alternative for reducing and controlling PP in conventional endodontic reintervention.

CLINICAL SIGNIFICANCE

The use of LPT in endodontic reintervention may be a safe and promising alternative to clinically efficacious agent for use in the management of PP in this procedure.

Evaluation of Different Root Canal Sealers on Post Operative Pain in Single Visit RCT - A Comparative Study

Aim

To evaluate and compare three different root canal sealers (Endo-Sequence BC, Bio Root RCS and Zinc Oxide Eugenol) on post operative pain in single visit root canal therapies.

Material and Methodology

60 subjects with age ranging from 18-60 years were randomly selected depending upon the inclusion criteria. The subjects were then divided into three groups with 20 patients in each. In all the patients' single visit root canal treatment was done followed by obturation using different sealers. In Group I Endo- Sequence sealer was used, in Group II Bio-Root RCS and in Group III Zinc Oxide Eugenol sealers were used respectively.

Results

statistically significant results were obtained on comparing the efficacy of three groups with Group I proving to be much effect among the three.

Conclusion

within the limitation of the study it can be concluded that though all the sealers were effective in reducing post-operative pain, patients with Endo Sequence BC sealers evaluated statistically significant results.

Evaluation of Pain Following the Use of Different Single-file Glide Path Systems: A Randomized Clinical Trial

INTRODUCTION

This study aimed to evaluate postoperative pain intensity following glide-path preparation using the ProGlider (PG) and WaveOne Gold Glider (WOGG) systems in asymptomatic teeth with necrotic pulp and periapical lesions.

METHODS

In this randomized clinical trial (ClinicalTrials.gov ID: NCT05955742) maxillary and mandibular molars with asymptomatic apical periodontitis of 78 patients (age, 18-65 years) were included. The patients were randomly divided into 3 groups: control (n = 26), PG (n = 26), and WOGG (n = 26). All the systems were used according to the manufacturer's instructions, and all the root canal treatments were completed by a single operator within 2 sessions. Postoperative pain was assessed using a numerical rating scale at 6, 12, 18, 24, 48, and 72 hours. Analgesics administered and abscess formation were also recorded. Statistical analyses were performed using the Mann-Whitney U, Bonferroni Dunn, Friedman, Chi-square, and Fisher exact tests.

RESULTS

The postoperative pain at 12 and 18 hours was lower in the WOGG group than in the other groups (P < .05). The postoperative pain scores at 6 and 24 hours were higher among women than among men (P < .05). The highest postoperative pain scores were observed at 6 hours (P < .05).

CONCLUSIONS

The WOGG glide-path file system was associated with less postoperative pain than the other systems. Abscess formation and analgesic use were higher in the PG group than in the other groups. Postoperative pain was greater in women than in men.

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.

Clinical correlation of salivary alpha-amylase levels with pain intensity in patients undergoing emergency endodontic treatment

BACKGROUND

Pain is usually subjective and thus it is challenging to describe its characteristics such as nature, intensity, and origin. Non-invasive methods such as assessing salivary alpha-amylase (SAA) may aid the practitioner to evaluate the pain intensity. Hence, the current study aimed to correlate the levels of SAA with the pain intensity in patients presenting with varied endodontic pain levels.

METHODS

Sixty patients who presented with varied intensities of endodontic pain were selected for the present study out of which seven patients were excluded/dropped, leaving a total sample of fifty-five patients for assessment. Mandibular molar with symptomatic irreversible pulpitis without periapical pathology were included in the study. A 5ml of un-stimulated was obtained from the patients, following which the local anesthesia was administered. Root canal treatment was then performed and the pain scores at pre-operative and post-operative were recorded. Additionally, salivary samples were collected after emergency endodontic treatment and sent for sialochemical analysis. IBM.SPSS statistics software 23.0 was employed to assess the obtained data.

RESULTS

A statistically significant drop in the pain score (P < 0.001) and SAA levels (P < 0.001) were observed post-operatively in the contract to pre-operative state. A strong positive correlation was reported between SAA levels and pain scores in patients undergoing emergency endodontic treatment at both time intervals namely pre-operative (P < 0.001) and post-operative (P < 0.001).

CONCLUSION

The results of this preliminary showed a strong association between the pain score and SAA levels in patients undergoing an emergency endodontic treatment.

Analgesic Efficacy of Ketoprofen Transdermal Patch versus Ibuprofen Oral Tablet on Postendodontic Pain in Patients with Irreversible Pulpitis: A Randomized Clinical Trial

Materials and Methods

In this randomized clinical trial, 64 patients who had mandibular first and second molars with irreversible pulpitis were randomly divided into two groups (n = 32) by stratified permuted block randomization. The experimental group used 60 mg KTP every 6 hours, and the control group received 400 mg ibuprofen tablets every 6 hours for 1 day. The severity of pain experienced by patients was quantified before and at 2, 4, 8, 12, 24, and 48 hours after endodontic treatment, using the numerical rating scale (NRS). Data were analyzed by using the t-test, Mann-Whitney test, and generalized estimating equation (GEE) (alpha = 0.05).

Results

The pain score was not significantly different between the two groups at the baseline or any other postoperative time point (P > 0.05). The reduction in the pain score was significant in both groups from 2 to 10 hours and 10 to 48 hours, postoperatively (P < 0.001). The interaction effect of time and group was not significant on the postoperative pain score in the abovementioned time intervals, and the pattern of pain reduction was the same over time in both groups (P > 0.05).

Conclusion

Both KTP and ibuprofen effectively decreased postendodontic pain. Considering the comparable pattern of pain reduction, KTP can be used as an alternative to ibuprofen tablets for effective pain control after endodontic treatment of mandibular first and second molars with irreversible pulpitis.

The Effect of Trypsin-Chymotrypsin on Postoperative Pain after Single Visit Endodontic Treatment: A Randomized Controlled Trial

INTRODUCTION

The efficacy of trypsin-chymotrypsin in postoperative pain management following single-visit root canal treatment of teeth with symptomatic irreversible pulpitis was evaluated. Additionally, synergistic effects with nonsteroidal anti-inflammatory drugs and reported side effects were also investigated.

METHODS

This prospective, parallel, triple-blinded phase IV randomized controlled trial included 60 patients with mandibular first molars exhibiting symptomatic irreversible pulpitis. The patients were randomly allocated using computer software to one of four treatment groups (n = 15 each), and either ibuprofen (600 mg), ambezim-G (trypsin 5mg-chymotrypsin 5 mg), a combination of both, or a placebo drug were administered postoperatively. The participants scored pain intensity at different time-intervals using a numerical scale, and passive surveillance of harm was used to detect clinical safety. Age was compared between groups using a one-way analysis of variance test. Pain scores were analyzed using the Kruskal-Wallis and Friedman's tests and, if significant, Dunn's test was used for pairwise comparisons. The chi-square test was used to compare qualitative data, and the significance level was set at P value ≤ .05.

RESULTS

All interventions were found to be effective in reducing postoperative pain, and no statistically significant differences were observed between the ibuprofen, trypsin-chymotrypsin, and combination groups. However, all 3 groups differed significantly from the placebo group. The safety profile of the interventions did not differ significantly.

CONCLUSIONS

Trypsin-chymotrypsin exhibits comparable efficacy to nonsteroidal anti-inflammatory drugs. No synergistic effects occur when the 2 are used in combination. This is the first randomized controlled trial to assess the effects of proteolytic enzymes on postendodontic pain.

TRIAL REGISTRATION

clinicaltrials.gov, Identifier: NCT05479747.

Effect of endodontic sealer on postoperative pain: a network meta-analysis

This systematic review and network meta-analysis aimed to answer the following focused research question: "Does the type of endodontic sealer affect the postoperative pain in patients who received endodontic treatment?" Different databases and grey literature were surveyed. Only one randomized controlled trial were included. The risk of bias in the studies was evaluated by using the Cochrane Collaboration's tool. A random-effects meta-analysis was conducted to compare the risk and intensity of postoperative pain. The quality of the body of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. Out of 11,601 studies, 15 remained for qualitative analyses and 12 for meta-analysis. Seven studies were classified at high risk of bias, and 8 studies raised some concerns. No significant differences between the endodontic materials were observed in the direct comparisons, both in risk and in intensity of postoperative pain (pairwise comparisons with 2 studies: I² = 0%; p > 0.05 and 8 studies: I² = 23%; p > 0.05, respectively). The certainty of the evidence was graded as low or moderate. There was no difference in the risk and intensity of postoperative pain after filling with different endodontic sealers. Further systematic reviews should be conducted.

Trial Registration

PROSPERO Identifier: CRD42020215314.

Incidence of postoperative pain after using single continuous, single reciprocating, and full sequence continuous rotary file system: a prospective randomized clinical trial

Background

Extrusion of debris is a major factor that results in postoperative pain during root canal treatment with various instruments and instrumentation techniques. Therefore, instrumentation techniques that extrude minimal debris into the periapical area while reducing pain are desirable. This study aimed to compare the incidence of postoperative pain and intake of analgesic medication (frequency and quantity) after endodontic treatment of mandibular posterior teeth using two single files and full-sequence continuous rotary systems with different kinematic motions.

Methods

Thirty-five of 105 patients were assigned equally to three groups according to the instrumentation system used: ProTaper Next (PN) X2, 25/06 (Dentsply, Maillefer, Ballaigues, Switzerland), One Shape (OS), #0.25/06 (Micro Mega, Besancon, France), and Wave One Gold (WG), Red - #0.25, 0.07 (Dentsply, Maillefer, Ballaigues, Switzerland). Five specialists were included in this study design; each professional prepared 21 teeth, and randomly selected 7 per instrument system. The VAS sheet ranging from 0 to 10 was used to record the initial and postoperative pains at 24, 48, and 72 h, and 7^th day after single visit endodontic treatment in mandibular premolars and molars with a diagnosis of asymptomatic irreversible pulpitis with or without apical periodontitis. Postoperatively, an analgesic, ibuprofen 400 mg was administered for intolerable pain at a dose of 1 tablet for 6 h. The patients were asked over the telephone regarding postoperative pain at intervals of 24, 48, and 72 h, and 7^th day using a visual analogue scale.

Result

There were no statistically significant differences among the PN, OS, and WG systems (P > 0.05) with regard to the incidence of postoperative pain at any of the four time points assessed.

Conclusion

The intensity of postoperative pain, frequency, and analgesic intake were similar across all three types of instrument systems; however, the reciprocating single file (WG) was associated with less postoperative pain than the full sequence continuous rotary file.

Severity of Post-Operative Pain after Instrumentation of Root Canals by XP-Endo and SAF Full Sequences Compared to Manual Instrumentation: A Randomized Clinical Trial

This investigation aimed to examine the post-operative pain experienced following single-visit root canal treatment using the XP-endo shaper sequence (XPS), full-sequence self-adjusting file (SAF), and manual K-files (HKF). A randomized equivalence parallel design, double-blinded clinical study was conducted on 120 patients with symptomatic irreversible pulpitis, with or without clinical signs of apical periodontitis. Only teeth with fully formed roots and no periapical lesions were incorporated in the study. Patients were apportioned to one of three groups (n = 40) randomly: Group 1-XPS, Group 2-SAF, and Group 3-HKF. Pre- and post-instrumentation pain was rated utilizing Visual Analog Scale (VAS) with a spectrum of 0-100 mm. The descriptive statistics and one-way ANOVA with 95% confidence intervals were used for statistical analysis. The mean VAS scores before instrumentation were consistent in all three groups. At 6, 24, 48, and 72 h, patients with root canals instrumented by SAF had the lowest post-instrumentation mean VAS score, followed by XPS. For all time intervals, the patients in the HKF group had the highest VAS score. The full-sequence SAF instrumentation resulted in less post-operative pain than the XP-endo plus protocol, while manual instrumentation with K-files resulted in the highest post-operative pain.

The Determination of Flare-Up Incidence and Associated Risk Factors During Endodontic Treatment: An Observational Retrospective Study

BACKGROUND

Endodontic flare-up signifies pain and/or swelling seen within a few days after an endodontic appointment by patients requiring an emergency. These are undesirable and unwanted as they cause great discomfort to the subjects and stress to the operator due to swelling and pain.

AIMS

This study aims to determine the flare-up incidence and associated risk factors during endodontic treatment.

METHODS

The present retrospective study assessed 1000 patients of both genders for endodontic flare-ups. Flare-up cases were patients having swelling or pain within 1-3 days after a root canal appointment and needing an emergency visit for relieving the symptoms. After data recording, it was subjected to statistical analysis to assess related factors, flare-up cause, and incidence rate using Fisher's exact test and chi-square test.

RESULTS

In the present study, the incidence rate of flare-ups is 9.4%. The majority of flare-ups were in the molar teeth followed by the anterior teeth and 6.7% (n=30) of the premolar teeth. For the number of canals, it was seen in 13.6% (n=24) of cases with multiple canals, 5.5% (n=12) of cases with two canals, and 9.6% (n=58) of cases with a single canal. In patients with no medical history, flare-ups were significantly less compared to patients with medical history (p<0.001). A significantly higher number of flare-ups were in the teeth having pulp necrosis with periapical lesions with 45.9% (n=34) (p<0.001).

CONCLUSION

Flare-ups are commonly seen in multiple canal teeth having pulp necrosis with periapical lesions with an associated medical history, with females being more prone to endodontic flare-up cases.

Post-Operative Endodontic Pain Management: An Overview of Systematic Reviews on Post-Operatively Administered Oral Medications and Integrated Evidence-Based Clinical Recommendations

Endodontic treatment comprises the overall management of pre-, intra- and post-operative symptoms, including post-operative endodontic pain, considered as a complication susceptible of chronicization. Post-operative pain is very common and highly unpreventable and has a multi-factorial etiology and a potential pathogenic link to the acute inflammation of the periapical area, secondary to localized chemical, mechanical, host and/or microbial damage occurring during endodontic treatment. Considering the multitude of heterogeneous technical and pharmacological approaches proposed to control post-operative endodontic pain, the present study primarily comprised an overview of systematic reviews of systematic reviews of randomized clinical trials, summarizing findings on post-operatively administered oral medications for post-operative endodontic pain control, in order to note the most effective type and dosage of such drugs. Secondarily, a narrative review of the current evidence on technical solutions to be observed during endodontic treatment procedures, to control post-operative pain, was conducted to provide integrated evidence-based clinical recommendations for optimal post-operative endodontic pain management.

Endodontic postoperative flare-up: An update

Endodontic treatment corresponds to a combined chemical and mechanical approach, followed by a three dimensional hermetic obturation, that eliminate the pulpal and periradiculare disease and boost healing and repair of periradiculare tissue. Despite the advances in the endodontic field, the inter-appointment flare up remains a true nightmare that encounters every dentist. This complication commences a few hours or days after root canal procedures and it is characterized by the development of pain and/or swelling, requiring an unscheduled appointment for emergency treatment. Different studies showed that flare-ups represent a multifactorial phenomenon including mechanical, chemical and microbial factors. In addition, a correlation was found between flare-up and age, gender, tooth type, presence of preoperative pain, tooth condition before treatment, irrigation techniques, number of visits as well as intracanal medication. Moreover, some medicine intake was proved to be efficient in controlling this postoperative pain. However, a clear procedure to avoid its occurrence is yet to be established. In this review, we summarize knowledge about the etiology of flare-up and its related factors. This could be effective in helping dentists to adapt some strategies to prevent it.

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 premedication on postoperative pain after root canal therapy in patients with irreversible pulpitis: a systematic review and meta-analysis

This systematic review aimed to assess the effect of premedication on postoperative pain after root canal treatment in vital teeth. Five electronic databases were searched for randomized clinical trials, and two independent reviewers selected eligible studies, extracted data, and assessed the quality of studies using the Cochrane Risk of Bias tool. Meta-analysis was conducted using the random-effects model, and the pooled effect estimate of the standardized mean difference (SMD) between premedication and placebo was calculated. Subgroup analysis was conducted based on the class and route of the drug. Studies with a high risk of bias were excluded from the sensitivity analysis. Ten trials satisfied the inclusion criteria, of which eight were included in the meta-analysis. Premedication was more effective in reducing postoperative pain than placebo at 6 hours (SMD = −1.00; 95% confidence interval [CI] = −1.33 to −0.66), 12 hours (SMD = −0.80; 95% CI = −1.05 to −0.56), and 24 hours (SMD = −0.72; 95% CI = −1.02 to −0.43). The results of the sensitivity analysis confirmed the findings of the primary analysis. Based on these results, it can be concluded that premedication is effective in reducing postoperative pain in teeth with irreversible pulpitis. However, additional quality studies are required for further validation.

Influence of maintaining apical patency in post-endodontic pain

BACKGROUND

The concept of instrumentation beyond the apical foramen by small flexible file to prevent apical blockage is apical patency. However, this procedure might endow postoperative pain, thus to maintain apical patency or not is the matter of dilemma. Hence, the primary objective of this study was to compare postoperative pain between apical patency and non-patency groups and secondary objective was to evaluate the influence of number of visits, vitality of teeth, group of teeth and preoperative pain on post-operative pain.

METHODS

Preselected (n = 178) patients based on group of teeth and status of pulp were randomly divided into 2 groups, apical patency and non-patency which was further treated in either single or multiple visits. After exclusion, 160 patients were included. Each group (n = 80) was subdivided in single visit (n = 40) and multiple visits (n = 40), including vital (n = 20) and non-vital teeth (n = 20) and single-rooted (n = 10) and multiple-rooted teeth (n = 10). Apical patency was maintained with a size 10 K-file during conventional hand filing step-back shaping procedure. Intensity of pain was recorded before treatment and on days 1, 2, and 7 after treatment using Numerical Rating Scale (NRS-11). Statistical analysis was done using Mann-Whitney U test, Spearman correlation and Multiple linear regression analysis.

RESULTS

The primary outcome of this study showed statistically significant difference (p < 0.05) in postoperative pain scores between patency and non-patency groups with higher pain scores in patency group on 1st, 2nd and 7th day follow up. The secondary outcome showed postoperative pain in patency-maintained group was influenced by status of the pulp and preoperative pain only. Vital teeth of patency-maintained group treated in multiple visits showed statistically significant (p = 0.02) post-operative pain in day 1 follow up. Pre-operative pain showed positive correlation with postoperative pain with statistically significant difference.

CONCLUSIONS

Our study concluded that maintenance of apical patency increased postoperative pain. Evaluation of influence of number of visits, status of pulp, group of tooth and preoperative pain revealed status of pulp and preoperative pain as influencing factors for postoperative pain in patency group.

Effect of Apical Third Enlargement to Different Preparation Sizes and Tapers on Postoperative Pain and Outcome of Primary Endodontic Treatment: A Prospective Randomized Clinical Trial

INTRODUCTION

The purpose of this study was to evaluate the effect of apical preparation size and taper on postoperative pain and healing after primary endodontic treatment.

METHODS

One hundred and twenty patients with asymptomatic mandibular first molars with radiographic evidence of periapical pathology and with a periapical index (PAI) score ≥3 were randomly assigned to 2 groups, group 1 and 2, based on apical enlargement to 2 and 3 sizes larger than the initial apical binding file (IABF), respectively. Each group was further divided into subgroups A and B depending on the apical enlargement taper of 4% and 6%, respectively. Endodontic treatment was performed, and the final apical enlargement in all the groups was performed as follows: group 1A, 2 sizes larger than the IABF with a 4% taper; group 1B, 2 sizes larger than the IABF with a 6% taper; group 2A, 3 sizes larger than the IABF with a 4% taper; and group 2B, 3 sizes larger than the IABF with a 6% taper. Postoperative pain was assessed at 6, 12, 24, 48, and 72 hours. Clinical evaluation and the change in the PAI score on radiographs were assessed at the 3-, 6-, and 12-month follow-ups.

RESULTS

No significant difference in postoperative pain was found. The success rate was lowest (57.1%) in group 1 subgroup A as evidenced by the significant change in the PAI score between group 1 subgroup A and the rest of the groups at the 6- and 12-month follow-ups.

CONCLUSIONS

Apical preparation to 2 sizes larger than the IABF with a 4% taper is insufficient and results in significantly lower success rates compared with larger preparation sizes and tapers.

Calcium Silicate-Based Sealers Do Not Reduce the Risk and Intensity of Postoperative Pain after Root Canal Treatment when Compared with Epoxy Resin-Based Sealers: A Systematic Review and Meta-Analysis

This review aims to evaluate whether root canal obturation with calcium silicate-based (CSB) sealers reduces the risk and intensity of endodontic postoperative pain when compared to epoxy resin-based (ERB) sealers. The review was registered at PROSPERO (CRD42020169255). Two independent reviewers conducted an electronic search in PubMed, Scopus, EMBASE, Web of Science, Cochrane Library and LILACS until November 2020 and included only randomized clinical trials with adult health participants undergoing root canal treatment. After selection, the JBI Critical Appraisal tool was used to assess the risk of bias. A fixed-effect meta-analysis was performed to summarize the results of pain risk and pain intensity at time intervals of 24 and 48 hours. Finally, the certainty of evidence was assessed using the GRADE approach. The search resulted in 1,206 records, of which five studies (n = 421 patients) met the eligibility criteria and presented moderate to low risk of bias. There was no significant difference between groups in the risk of pain in the first 24 hours (relative risk or RR = 0.83, 95% confidence interval or CI: 0.60, 1.16, I 2 =) or 48 hours (RR = 0.56, 95% CI: 0.26, 1.21, I 2 =). Silicate-based sealers led to lower pain intensity only at 48 hours (mean and standard deviation = 0.37, 95% CI: 0.69, 0.05). All analyses revealed low heterogeneity (I 2 < 25%). The evidence presented moderate level of certainty. Currently available evidence has shown that there is no difference between CSB and ERB sealers in the risk or intensity of postoperative pain.

Glide path enlargement of curved molar canals using HyFlex EDM glide path file versus PathFile: a comparative study of preparation time and postoperative pain

Background

This randomized clinical trial aimed to compare the preparation time and severity of postoperative pain between HyFlex Electric Discharge Machine (EDM) glide path file (GPF) and PathFile.

Methods

Eighty patients whose molar teeth had at least one severely curved canal were treated by the same specialist. After access cavity preparation, the patients were randomly assigned to receive glide path enlargement with either HyFlex EDM GPF or PathFile. ProTaper Next X1 and X2 files were used to prepare the canals. The time of preparation was assessed and the severity of postoperative pain over the next 7 days was recorded. The preparation time and the postoperative pain scores were compared using the Linear Mixed Models (P ≤ 0.05).

Results

Glide path enlargement time was significantly shorter with HyFlex EDM GPF (27.828 ± 2.345 s) than with PathFile (48.942 ± 2.864 s) (P < 0.001). The highest postoperative pain score was recorded on the first day and the pain decreased over time in both groups. HyFlex EDM GPF group patients reported significantly less postoperative pain than PathFile group patients overall (P < 0.001).

Conclusions

Postoperative pain and glide path preparation time could be reduced by using HyFlex EDM GPF system.

Trial registration PKUSSNCT, PKUSSNCT-17B12, Registered 24 October 2017.

Postoperative Pain after Endodontic Treatment under Irrigation with 8.25% Sodium Hypochlorite and Other Solutions: A Randomized Clinical Trial

INTRODUCTION

The aim of this study was to evaluate the postoperative pain in patients after endodontic treatment using 8.25% sodium hypochlorite (NaOCl) compared with other concentrations and 2% chlorhexidine (CHX).

METHODS

In this double-blind randomized trial, 180 patients were evaluated who underwent a single session of endodontic treatment under irrigation with 2.5%, 5.25%, or 8.25% NaOCl or 2% CHX solutions. The presence of postoperative pain was assessed 24, 48, and 72 hours after treatment and recorded using the visual analog scale (VAS). A descriptive analysis, logistic regression, and Wald test were performed.

RESULTS

Altogether 169 patients participated, of whom 107 were women, and the mean age was 38.1 ± 14.4 years. No significant differences occurred between the irrigants and the pain outcomes, not even for the use of postoperative pain medication and responses to VAS (P > .05). In the multivariate model including irrigants, after 24 hours or at any time, a significant difference (P < .05) remained in preparation time ≥10 minutes and the presence of overfilling. Also, in relation to the VAS, the overfilling presented significantly different results (P < .05).

CONCLUSIONS

There was no significant difference in the presence of postoperative pain between the 8.25% NaOCl and the other irrigation solutions. However, the extended preparation time and the overfilling material were responsible for the increase of postoperative pain.

Effect of Different Host-Related Factors on Postoperative Endodontic Pain in Necrotic Teeth Dressed with Interappointment Intracanal Medicaments: A Multicomparison Study

Objectives  The current study aimed to assess the impact of factors such as age, gender, and the tooth type on postoperative endodontic pain in necrotic teeth with symptomatic periapical periodontitis and radiolucency dressed randomly with either calcium hydroxide or propolis paste.

Materials and Methods  The standard chemomechanical root canal preparation of 80 teeth was performed by the primary investigator. The intracanal medicaments were inserted by the secondary operator. Patients self-recorded their postoperative endodontic pain intensity with the help of visual analog scale at 4, 12, 24 (day 2), 48 (day 3), and 72 (day 4) hours. During analysis, patients (68/80) were grouped according to gender, age, and the tooth type.

Statistical Analysis  Mann–Whitney’s U test was applied for mean pain score comparison between genders and between tooth type. Kruskal–Wallis’ test was applied for mean pain score comparison between the age groups.

Results  No significant difference ( p > 0.05) in pain scores was found between the age groups and between the tooth types. Males had significantly higher pain scores as compared with females at days 2 ( p = 0.035), 3 ( p = 0.023), and 4 ( p = 0.020).

Conclusion  The results suggested that there was no impact of age and tooth types on postoperative endodontic pain.

Postoperative pain in endodontic retreatment of one visit versus multiple visits: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The aim of this systematic review and meta-analysis (SRM) was to assess the postoperative pain (PP) after non-surgical endodontic retreatment (NSER) in a one visit compared to multiple visits. The PICO question used was "Does NSER in patients with unsatisfactory endodontic treatment in a one-visit visit have a similar PP to that of NSER in multiple visits?"

MATERIALS AND METHODS

This systematic review followed PRISMA and was registered in PROSPERO (CRD42019136700). Searches were performed in the PubMed/MEDLINE, Scopus, and the Cochrane Library databases for articles published until September 2020. The eligible criteria were randomized clinical trials (RCTs). The meta-analysis was based on the Mantel-Haenszel. The PP after the retreatment was analyzed using a dichotomous outcome, measured according to risk ratio (RR) when p < 0.05. The Cochrane scale was used to assess risk of bias, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence.

RESULTS

Four studies were included. In general analysis without considering intensity, one-visit NSER presented lower PP than the multiple visits only for 1 and 30 days [(RR = 0.67; CI: 0.48 to 0.93; p = 0.02), and (RR = 0.09; CI: 0.01 to 0.66; p = 0.02)], respectively. Regarding sub-analysis considering the intensity, one visit present lower mild PP when compared with multiple visits [(RR = 0.54; CI: 0.30, 0.96; p = 0.04); (RR = 0.33; CI: 0.12, 0.88; p = 0.03); and (RR = 0.12; CI: 0.02, 0.86; p = 0.03)], respectively. However, sub-analysis for moderate and severe PP showed no significant difference, independently of period evaluated (p > 0.05). Regarding the risk of bias analysis, a low risk was observed for most domains, except allocation that was considered unclear, while the certainty of evidence for each analysis was considered low.

CONCLUSION

Within the limitations of study, the one and multiple visit can be considered adequate, because both present a similar occurrence of PP, except for mild pain. However, due to the low number of studies, further well conducted and standardized RCTs are needed to reassess these results.

CLINICAL RELEVANCE

Both therapies of endodontic retreatment can be considered in clinical practice. Therefore, the endodontist must consider the patient's individual characteristics and experience to consider the best treatment approach.

The Effect of Adding Clonidine to Articaine and Epinephrine on Post-treatment Pain: A Randomized Clinical Trial Study

Introduction

Articaine is reported to have a fast onset and a short-acting pulpal anesthesia in inferior alveolar nerve blocks. Clonidine is an α ₂-adrenoceptor agonist and is used as an adjunct to enhance the anesthetic efficacy and induce greater analgesia. In an attempt to search for more effective ways to achieve profound analgesia after root canal treatment, this randomized clinical trial assessed the efficacy of clonidine added to articaine/epinephrine solution on post-operative pain relief after root canal treatment in mandibular molars with irreversible pulpitis.

Materials and Methods

Our randomized clinical trial study enrolled one hundred patients with symptomatic irreversible pulpitis in mandibular molars. They were divided into two groups, each group received either 0.2 mL 150 µg/mL clonidine or distilled water added to 1.8 mL of 4% articaine with 1:100,000 epinephrine cartridge. The alveolar nerve block in the two groups was administered by the same clinician and the subject's pain scores were recorded at 6, 12, 24, 48 and 72 h post-operatively using a Heft-Parker visual analog scale. Data were analyzed using t, chi-square and repeated-measures ANOVA statistical tests.

Results

The mean pain scores for clonidine group were significantly lower than control at all the time intervals after treatment (P<0.05). We did not notice any clinical and there were no complaints from the patients either.

Conclusion

Based on this randomized clinical trial study the addition of clonidine to the articaine/epinephrine solution using an inferior alveolar nerve block during root canal treatment in mandibular molars with irreversible pulpitis may be effective in reducing post-operative pain.

Effectiveness of Intracanal Cryotherapy in Root Canal Therapy: A Systematic Review and Meta-analysis of Randomized Clinical Trials

INTRODUCTION

The effectiveness of intracanal cryotherapy for reducing postoperative pain is unclear. The objective of this systematic review was to evaluate the effect of intracanal cryotherapy on postoperative pain after root canal therapy in patients with pulpal or periradicular pathosis.

METHODS

We searched PubMed, Embase, Scopus, and the Cochrane Library as well as the top 3 endodontic journals for relevant articles. We included randomized controlled trials that included adults. Our main outcome was postoperative pain intensity measured with a validated scale. We assessed the risk of bias using the Cochrane criteria and the quality of the included studies using Grading of Recommendation Assessment, Development, and Evaluation. We used a random-effects model for meta-analysis.

RESULTS

Eight studies involving 810 patients were included. The overall risk of bias was moderate. Seven of 8 studies used a visual analog scale to measure pain intensity. Compared with controls, intracanal cryotherapy significantly reduced postoperative pain at 6 (mean difference = -1.37; 95% confidence interval [CI], -0.61 to -2.14; P < .05; I2 = 76%; moderate-quality evidence) and 24 hours after the procedure (mean difference = -1.43; 95% confidence interval, -0.70 to -2.15; P < .05; I2 = 89%; moderate-quality evidence). There was no significant effect on pain at 48 and 72 hours and 7 days after the procedure.

CONCLUSIONS

Moderate-quality evidence suggests that intracanal cryotherapy (ie, using cold saline irrigation as a final irrigant) significantly reduces the intensity of pain at 6 and 24 hours after root canal therapy. Future clinical trials assessing the effectiveness of intracanal cryotherapy are advocated.

Effect of Bioactive Glass-Based Root Canal Sealer on the Incidence of Postoperative Pain after Root Canal Obturation

The purpose of this study is to evaluate the effect of a bioactive glass-based root canal sealer, Nishika Canal Sealer BG (CS-BG), on the incidence of postoperative pain (PP) after root canal obturation (RCO). Eleven dentists performed pulpectomy or infected root canal treatments for 555 teeth. During RCO, CS-BG was used. After RCO, the rate of PP and the factors affecting PP (pain during RCO and pain immediately after RCO) were analyzed. PP was observed in eight teeth (1.5%), and within 7 days after RCO, there were no teeth with pain. In these teeth with PP, there was a significant difference in the occurrence of pain during RCO, but not in the occurrence of pain immediately after RCO, when compared with pulpectomy and infected root canal treatment. These clinical results show that CS-BG has an excellent biocompatibility, and can suppress the distress of patients during RCO.

Expression of NaV-1.7, TNF-α and HSP-70 in experimental flare-up post-extirpated dental pulp tissue through a neuroimmunological approach

Background

Dental caries continue to represent a major problem which, if left untreated, will cause irreversible pulpitis. Root canal treatment constitutes one potential treatment intended to preserve teeth afflicted with irreversible pulpitis. During root canal treatment, pain or swelling, referred to as flare-ups, can occur at any point in the process.

Aim

To analyze the molecular aspect of the phenomenon of flare-up in vital dental pulp tissue following mechanical and bacterial trauma (extirpation and lipopolysaccharide [LPS] induction respectively) through a neurological approach, based on the expression of NaV-1.7 in neuron cells, and HSP-70, TNF-α in macrophage cells.

Method

This laboratory experimental study was conducted using 15 Spraque Dawley rats as subjects which were divided into three groups of five subjects: a control group, a pulp tissue extirpation group and an LPS induction followed by extirpation of pulp tissue group. Test samples were collected from the apical field of the mandibular incisor and subsequently examined using immunohistochemical methods.

Results

There were significant differences in NaV1.7, HSP70 and TNFα expression between the treatment groups. While a marked increase in the expression of HSP70 occurred, both Nav1.7, and TNFα expression decreased significantly.

Conclusion

Extirpating the dental pulp tissue will induce a more pronounced flare-up response from the molecules of the pulp tissue in vital teeth than those in inflamed vital pulp tissue.

An Evaluation of Ibuprofen Versus Ibuprofen/Acetaminophen for Postoperative Endodontic Pain in Patients With Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis

The purpose of this investigation was to compare ibuprofen versus an ibuprofen/acetaminophen combination for postoperative pain control in a patient model specific to teeth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis. One hundred and two patients presenting with moderate to severe pain from a maxillary or mandibular posterior tooth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis were included. Following local anesthetic administration, complete endodontic cleaning and shaping was performed. Patients were randomly assigned to receive identically appearing tablets of ibuprofen 200 mg or a combination of ibuprofen 200 mg/acetaminophen 216.7 mg with instructions to take 3 tablets every 6 hours as needed for pain. Patients were also given a prescription for an escape medication to take if the study medications did not adequately control their pain. A 4-day diary was used to record pain ratings and medication use. Moderate to severe pain was experienced by 59-61% of the patients on postoperative day 1 and 50-57% of the patients on day 2, with the pain ratings decreasing over the next 2 days. There were no statistically significant differences between the 2 groups in postoperative pain, percussion pain, or medication use. There was no difference between ibuprofen and the combination of ibuprofen/acetaminophen in the reduction of postoperative pain following endodontic debridement in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.

An insight into patient's perceptions regarding root canal treatment: A questionnaire-based survey

Background:

A key setback of root canal treatment (RCT) is that most patients lack adequate knowledge about it. Understanding and identifying the factors that hinder or discourage patients from undergoing RCT is necessary to adequately address the issue. The review of literature shows that there is a paucity of data about the awareness and acceptance of RCT among patients in Indian population. Thus, the study was conducted with aim to assess patients’ awareness of RCT among patients reporting in Desh Bhagat Dental College and Hospital, Mandi Gobindgarh. By surveying the patients, a broad patient perspective on the issue was sought.

Materials and Methods:

This survey was conducted with the help of prestructured questionnaire consisting of 15 questions, distributed to random 450 patients coming to the outpatient department of Conservative dentistry and Endodontics in Desh Bhagat Dental College and Hospital. The completed questionnaires were then analyzed to assess patients’ experiences, concerns, and perceptions about RCT.

Results:

There is a lack of awareness among patients regarding RCT.

Conclusion:

It is important to create more awareness among the populace of our country about the significance of maintaining a healthy dentition and attendant sequel if not done so. More patients would consider having endodontic procedures if properly made aware of.

The Effect of Reciprocating and Rotary Systems on Postoperative Endodontic Pain: A Systematic Review and Meta-analysis

Introduction

The objective of this study was to evaluate the influence of the instrumentation kinematics on endodontic postoperative pain.

Methods and Materials

PubMed, Scopus, Web of Science, Lilacs, Cochrane Library and the System for Information on Gray Literature in Europe were searched electronically without time or language limitations up to June 2020. Subsequently, data extraction, quality assessment and meta-analysis were conducted. The meta-analysis was performed using random-effects inverse-variance methods, and heterogeneity was tested using the I 2 index (P<0.05).

Results

A total of 318 articles were successfully identified in the search. Sixteen studies were used in qualitative synthesis and fourteen used for quantitative synthesis. Meta-analysis showed that patients treated with reciprocating system had lower risk of pain 48 h after endodontic treatment (Risk ratio [RR]=1.04, 95% Confidence interval [CI]=1.01-1.06, P=0.003) (I2=0%), but the mean postoperative pain for the reciprocating system was greater 24 h post endodontic treatment (Standardized mean difference [SMD]=0.25, 95% CI=0.06 to 0.44, P=0.01) (I2=43%). Other time points presented similar rates of postoperative pain (P>0.05). The certainty of evidence ranges from very low to high.

Conclusions

The rate of postoperative endodontic pain was low, and reciprocating systems evoked more pain within the 24 h interval. Overall, the incidence and level of postoperative pain did not vary between reciprocating and rotary systems. There is no consensus if there is a relationship between the kinematics (rotary and reciprocating) and the incidence of postoperative 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.

Single dose oral prednisolone and post-operative endodontic pain

DesignA randomised, single centre, double blind placebo controlled clinical trial involving 400 patients.InterventionThe inclusion criteria comprised systemically healthy patients between the ages of 18 and 35 years having mandibular molars with symptomatic irreversible pulpitis, radiographically normal periapical area and no pain on biting or percussion. The study was approved by the Institutional Review Board of Ethics Committee at the School of Dentistry, Cairo University, Egypt. Patients were recruited from the outpatient clinic of the Department of Endodontics.The independent Centre for Evidence Based Dentistry performed sequence generation and allocation concealment. For allocation concealment, two tablets of each medication were placed in sequentially numbered, opaque, sealed containers. Participants and operators were unaware of the assigned group for the duration of the study. Post-graduate students were calibrated to act as operators and supervisors from the department of endodontics evaluated their clinical performance.The participants received 40 mg of prednisolone or placebo tablets 30 minutes before single visit root canal treatment. Patients recorded the pain level 6, 12 and 24 hours after treatment on a 100mm visual analogue scale. All patients received a sham capsule to take if needed as a postoperative analgesic. If pain persisted an analgesic was prescribed.Outcome measureThe primary outcome was the incidence of postoperative pain at three points; 6, 12 and 24 hrs. The secondary outcomes were pain intensity and the incidence of analgesic consumption. The relative risk reduction (RRR) and the number needed-to-treat (NNT) and their 95% confidence intervals (CI) were used to represent the risk of pain incidence.ResultsOf the 670 patients assessed for eligibility, 400 were included in the study. Only two patients of the 400 were lost to follow-up with 398 patients (prednisolone group = 198; control group = 200) being included in the analysis; 259 were women and 141 men. The mean age was 29.45 -/+ 3.7 years in the prednisolone group and 28.97 -/+3.61 years in the control group. There was no significant difference for mean age (P = 0.164), gender distribution P = 0.123) or tooth type (P = 0.56) between the two groups. The relative risk reduction in pain incidence was 20.31% (95% CI: 12.03%, 27.82%) at six hours, 23.39% (95% CI: 14.75%, 31.16%) at 12 hours and 28.85% (95% CI: 18.08%, 38.20%) at 24 hours. Prednisolone had significantly less post-obturation pain intensity compared to placebo at 6, 12 and 24 hours (P < 0.001). The relative risk reduction in sham-capsule intake was 54% (95% CI: 38%, 66%) and in analgesic intake was 55% (95% CI: 3%, 79%). No adverse effects were recorded. The NNT (number needed to treat) was five (95% CI: 4, 9) at six hours, five (95% CI: 4, 8) at 12 hours and four at 24 hours (95% CI: 3, 7).ConclusionsPreoperative oral administration of a single dose of 40 mg prednisolone was beneficial for the control of postoperative pain up to 24hrs after single visit root canal treatment in patients with symptomatic irreversible pulpitis. The incidence of postoperative pain level and the need for postoperative analgesic intake decreased. The non-invasive route and minimal possible adverse events results in a favourable risk benefit-balance.

Post endodontic pain following single-visit root canal preparation with rotary vs reciprocating instruments: a meta-analysis of randomized clinical trials

Background

In endodontic therapy, continuous rotary instrumentation reduced debris compared to reciprocal instrumentation, which might affect the incidence of post-endodontic pain (PP). The aim of our study was to assess whether PP incidence and levels were influenced by the choice of rotary or reciprocal instruments.

Methods

In this meta-analysis the Pubmed and EM databases were searched for prospective clinical randomized trials published before April 20, 2016, using combinations of the keywords: root canal preparation/instrumentation/treatment/therapy; post-operative/endodontic pain; reciprocal and rotary instruments.

Results

Three studies were included, involving a total of 1,317 patients, 659 treated with reciprocating instruments and 658 treated with rotary instruments. PP was reported in 139 patients in the reciprocating group and 172 in the rotary group. The PP incidence odds ratio was 1.27 with 95% confidence interval (CI) (0.25, 6.52) favoring rotary instruments. The mild, moderate and severe PP levels odds ratios were 0.31 (0.11, 0.84), 2.24 (0.66, 7.59) and 11.71 (0.63, 218.15), respectively. No evidence of publication bias was found.

Conclusions

Rotary instrument choice in endodontic therapy is associated with a lower incidence of PP than reciprocating instruments, while reciprocating instruments are associated with less mild PP incidence.

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.

Incidence of postoperative pain after use of calcium hydroxide mixed with normal saline or 0.2% chlorhexidine digluconate as intracanal medicament in the treatment of apical periodontitis

OBJECTIVE

To compare the incidence of postoperative pain after the use of calcium hydroxide powder mixed with normal saline or 0.2% chlorhexidine digluconate as intracanal medicament.

PARTICIPANTS

Fifty-five subjects aged 17-60 years with teeth diagnosed to have apical periodontitis.

INTERVENTION

Two-visit conventional root canal treatment of seventy teeth. The teeth were divided by randomization (balloting) into two groups: control group and experimental group, each with thirty-five teeth treated with calcium hydroxide mixed with normal saline or with 0.2% chlorhexidine digluconate as intracanal medicament respectively. Incidence of postoperative pain was assessed using the universal pain assessment tool and whether or not analgesic was taken.

MAIN OUTCOME MEASURED

Incidence of post-operative pain.

RESULT

Postoperative pain occurred only at 1-day and 1-week reviews. In the control group, the overall incidence of pain was the same at both review periods (5.7%), while the experimental group showed a slight decrease in incidence between 1-day (17.2%) and 1-week (11.4%) reviews. Incidence of flare-ups was more in the experimental group (11.4%) than in the control group (5.7%). No significant statistical differences between the two groups were observed (p > 0.05).

CONCLUSION

The incidence of postoperative pain was lower in the normal saline treatment group, but the difference was not statistically significant.

Incidence of post-obturation pain after single-visit versus multiple-visit non-surgical endodontic treatments

BACKGROUND

Post-obturation pain is frustrating to both patients and dentists. Its incidence may change with the use of contemporary endodontic techniques. This randomised clinical trial aims to compare the incidence of post-obturation pain at one and seven days after single-visit and multiple-visit non-surgical endodontic treatments.

METHODS

Patients who required primary endodontic treatment in the two clinical trial centres in Hong Kong (HK) and in Beijing (PK) were recruited. Three HK dentists and three PK dentists performed endodontic treatments on 567 teeth using the same procedures and materials, either in a single visit or over multiple visits, using either core carrier or cold lateral condensation for obturation.

RESULTS

The attrition rate was 5.1%, and a total of 538 teeth were evaluated. Among these teeth, 232 (43%) were operated in HK, 275 (51%) were treated in a single visit, and 234 (43%) were treated using core carrier obturation. Logistic regression analysis showed that teeth with apical periodontitis (OR = 0.35, 95% CI = 0.21-0.57, p < 0.01) and less pre-operative pain (OR = 1.10, 95% CI = 1.03-1.18, p < 0.01) had lower incidences of post-obturation pain after one day. The incidences of post-obturation pain after one day for single-visit and multiple-visit treatments were 24.7% (68 of 275) and 33.5% (88 of 263), respectively (p = 0.50). The incidences of post-obturation pain after seven days for single-visit and multiple-visit treatments were 4.0% (11 of 275) and 5.3% (14 of 263), respectively (p = 0.47).

CONCLUSIONS

There was no significant difference in the incidences of post-obturation pain after one day and seven days with single-visit or multiple-visit endodontic treatments.

TRIAL REGISTRATION

ChiCTR-IOR-15005989.