3. Contents:
• Introduction
• Definition of pain
• Causes of endodontic pain
• Pretreatment endodontic pain
– Causes
– Management
• Pharmacological
• Non-pharmacological
• Interappointment/ during treatment pain
– Hot tooth
– Flare ups
– Management
• Post treatment pain
– Causes
• Clinician controlled factors
• Host related factors
• Microbial causes
– Various factors influencing post
endodontic pain
• Conclusion
• References
4. • Managing pain can be one of the most challenging aspects of clinical practise of endodontics
and one by which the skill of clinician is often judged.
• Pain control is a major issue in dental practice. Studies have shown that the major reason
why over 50% of adult do not seek routine dental care is the fear of pain.
• The objective of root canal therapy is to relieve and/or prevent associated pain and suffering.
Introduction:
5. Definitions:
• Pain is described as “an unpleasant sensory and emotional experience associated with
actual or potential tissue damage”
– The international association for study of pain
• It can also be described as “An unpleasant emotional experience usually initiated by
noxious stimulus and transmitted over specialized neural network to CNS where it is
interpreted as such.”
- Mohneim
6. • Endodontic pain can originate from the pulp or the periradicular area.
• Dental pain is mainly related to two factors, namely chemical mediators and pressure.
• Chemical mediators cause pain directly by lowering the pain threshold of sensory nerve
fibers or by increasing the vascular permiability and producing edema.
• Increased fluid pressure resulting from edema also stimulates the pain receptors.
10. • The initial phase of treating the endodontic pain is proper diagnosis.
• It is said that Diagnosis must be the starting point for pain management.
• It is imperative that the clinician should remain objective and perform the necessary
diagnostic procedures in a consistent manner, so as not to be misled by patients
misperception.
11. • Establish chief complaint
• Let the patient describe the chief complaint in their own words.
• History of chief complaint:
• Once the patient has described his chief complaint , questions can then be directed to the
nature of their discomfort that aid in diagnosis.
• The questions include:
• when did pain start?
• Intensity of pain
• Is it spontaneous
• What are aggravating factors?
• Relieveing factors
Diagnostic sequence:
12. Medical and dental history:
• Medical history can sometime help to provide diagnosis for example sinusitis could be the
reason for dental pain in upper arch
• Dental history is also quite important and may offer clues not only to the etiology of the
current problem but also helps determine the patients motivation to retain their teeth, which
may impact on treatment planning decision.
13. • Clinical examination:
• Visual examination
• Periodontal probing
• Periapical tests:
– Percussion
– Palpation
• Traumatic occlusion, sinusitis and periodontal disease are all example of potential source of
periradicular symptoms.
• A sharp, non lingering pain on biting pressure, in the absence of tenderness on percussion
and palpation is a typical finding of cracked tooth.
14. • Pulp tests:
– Exaggerated, lingering responses to either hot or cold are indicative of irreversible pulpal
inflammation.
– Reversible pulpitis pain will not be lingering in nature.
• Radiographic examination:
16. Treatment options:
• Optimal pain management combines both pharmacological and non-pharmacological
treatments.
Pain management
pharmacological
-Analgesics
-Local anesthesia
-Antibiotics
-Steroids
-Sedatives and tranquilizers
Non-pharmacological
-Pulpotomy
-Pulpectomy
-Debridement of canal
-Incision and drainage
17. Pharmacological strategies:
• Treating endodontic pain by drugs alone is not a definitive intervention. Instead , the
pharmacological management of pain should be considered together with definitive dental
treatment as a combined therapeutic approach for managing odontogenic pain.
NSAIDS:
• Ibuprofen: 400mg every 4hrs to 6hrs.
• Nalfon: 200-400 mg every 4-6 hrs.
• Naproxin sodium: 550mg starting dose then 275 mg 6-8 hrs.
• Flurbiprofen: 200 mg starting dose. 300 mg total daily dose.
18. COX-2 inhibitors:
• Celecoxib: 100-200 mg twice a day.
• Rofecoxib: 50 mg per day.
• Valdecoxib: 20 mg twice a day.
Local anaesthetics:
• For profound anesthesia, two types of anesthetic solution are used in endodontics.
• Lidocaine( xylocaine) and mepivacaine.
• For maxillary teeth and mandibular anteriors, 1.8 ml is advised.
• For mandibular poasteriors, 3.6 ml is advised.
19. Sedatives and tranquilizers:
• These drugs are central nervous system depressant and decrease cortical excitability.
• Use of tranquilizers is excellent in endodontic therapy.
• It eliminate the more objectionable types of patient defence reactions and produce acceptable
skeletal muscle relaxation.
• Sedatives and tranquilizers, both potentiate the action of local anethetics.
• Examples:
– diazepam( valium): 5-10 mg/ day
– Lorazepam: 2-4 mg/day.
20. Steroids:
• Bane k et al (2016), in their study established that methylprednisolone injection for acute
pulpitis had relieved the pain by a minimally invasive pharmacologic approach.
Randomized Clinical Trial of Intraosseous Methylprednisolone Injection for Acute
Pulpitis Pain. Journal of Endodontics Volume 42, Issue 1, January 2016, Pages 2–7
21. Antibiotics:
• The best available clinical evidence signals no indications for prescribing antibiotics
preoperatively or postoperatively to prevent endodontic infection or pain unless the spread of
infection is systemic, the patient is febrile, or both.
• Generally, an accurate diagnosis coupled with effective endodontic treatment will decrease
microbial flora enough for healing to occur.
Aminoshariae A, Kulild J. Evidencebased recommendations for antibiotic usage to treat endodontic
infections and pain : A systematic review of randomized controlled trials. The Journal of the American
Dental Association Volume 147, Issue 3, March 2016, Pages 186–191
23. • Achieving profound pulpal anesthesia is a corner stone in endodontic practise.
• Profound pulpal anesthesia during root canal procedure benefits not only the patient, but also
the dentist who will be less stressed worrying about patient reactions or sudden movement
during therapy.
• But sometimes it is not easy to anesthetize few teeth. Classic example of such case is “HOT
TOOTH”.
24. • Hot tooth : generally refers to a pulp that has been diagnosed with irreversible pulpitis, with
spontaneous , moderate to severe pain.
• A very common example of one type of hot tooth is a patient who is sitting in the waiting
room, sipping on a large glass of ice water to help control the pain.
Nusstein J M. Local anesthesia stratergies for patient with hot tooth. DCNA april 2010;
vol 54, num 2
25. How to check whether the tooth is anesthetized or not???
• Objective tests should be used to assess the level of anesthesia.
• Use of electric pulp tester and the application of cold refrigerant have been shown to
accurately determine pulpal anesthesia in teeth with a vital pulp before treatment.
• Teeth with necrotic pulp chambers but whose root canals contain vital tissue may not be
tested using the above means. In these cases , testing for pulpal anesthesia of neighboring
teeth may give the clinician an indication of the anesthestic status of the tooth to be treated.
26. Why tooth is not anesthetized???
• Inflamed tissue has lower pH, which reduces the amount of the base form of the anesthetic
needed to penetrate the nerve sheath and membrane. Therefore , there is less ionized form of
the anesthetic within the nerve to produce anesthesia. This theory may explain only the local
effects of inflammation on the nerve.
• Another theory is nerve arising from the inflammed tissue have altered resting potentials and
reduced thresholds of excitability.
• Other theories have looked at the presence of anesthetic- resistant sodium channels.
27. In cases of hot tooth where pulpal anesthesis is not achieved, the stratergies are:
• First consideration could be to change the LA agent.
– Supplementing an incomplete articaine IANB with articaine infiltration raises the
anesthetic success more effectively compared with lidocaine in mandibular molars with
irreversible pulpitis.
– Although studies have shown not much difference, so it might not be that helpful.
• Increasing volume
– But it had also not shown significant higher results.
Efficacy of Articaine versus Lidocaine in Block and Infiltratio Anesthesia Administered in Teeth
with Irreversible Pulpitis A Prospective, Randomized, Doubleblin Study. Journal of
Endodontics Volume 39, Issue 1, January 2013, Pages 6–10
28. • The next strategy would be to change the injection technique in attempting to block the
inferior alveolar nerve.
– For example, Gowgates technique has been reported to have a higher success rate than
the conventional IANB.
– But few studies have contradicted this superiority.
• Accessory nerves have also been implicated as a potential reason for the failure the nerve
block. Therefore along with block supplementary block/ infiltration could be advised.
– For example, the incisive nerve block at the mental foramen has been shown to improve
anesthetic success rate of IANB.
29. • There are several supplemetal techniques that are used:
– Intraligamentary (periodontal ligament) injection.
– Intraosseous injection
– Buccal infiltration
– Intrapulpal injection
• Other strategies to improve success of nerve block:
– Recent clinical studies have looked at the use of oral medications before treatment to
improve the success of nerve block.
– Ianiro et al used pretreatment oral dose of acetaminophen or a combination of
acetaminophen and ibuprofen versus placebo in patients undergoing endo therapy. They
reported that a trend toward higher success rates of 71% to 76%, respectively as
compared with placebo (46%).
30. Inter-appointment pain:
• Knowledge of the causes of and mechanisms behind inter-appointment pain in endodontics is
of utmost importance for the clinician to properly prevent or manage this undesirable
condition.
• The causative factors of inter-appointment pain encompass mechanical, chemical, and
microbial injuries to the pulp or periradicular tissues, which are induced or exacerbated
during root canal treatment.
31. • Flare-up is a well known complication that disturbs both patients and dentists. It is mainly
because of mechanical and chemical injuries that are often associated with iatrogenic factors.
• According to cohen it is defined as “ an acute exacerbation of a periradicular pathosis
after initiation or continuation of nonsurgical root canal treatment.”
• It can also be defined as the “occurrence of severe pain and swelling following an
endodontic treatment appointment, requiring an unscheduled visit and active treatment.”
Clinical and pharmacological management of endodontic flareup
Journal of Pharmacy and Bioallied Sciences. 2012 Aug; 4(Suppl 2): S294–S298.
32. Imura N et al. Factors associated with endodontic flare-ups a prospective study. International
Endodontic journal 1995, 28, 261-265
• The aetiological factors for such sequelae are complex and involve various aspects that can
be divided into three main areas:
– Treatment routine and clinical procedures that are under the control of the operator;
– Microbial factors related to the contents of the infected root canals (Seltzer & Naidorf
1985); and
– Host factors such as patient demographics (gender, age and tooth group), local tissue
changes, immunological phenomena, and finally, various psychological factors (Seltzer&
Naidorf 1985; Torabinejad etal 1988),
33. Microbial causes:
• There are some special circumstances in which microorganisms can cause
interappointment pain as a result of imbalance in host-bacteria relationship induced by
intracanal procedures.
• Presence of pathogenic bacteria
• Presence of virulent clonal types
• Microbial synergism or additism
• Number of microbial cells
• Secondary intraradicular infections
• Environmental cues: If the root canal environmental conditions are altered by
intracanal procedures and become conducive, microbial virulence can be enhanced
and inter-appointment pain can ensue.
34. Secondary intraradicular infections:
– Secondary intraradicular infections are caused by microorganisms that were not present
in the primary infection and have gained entry into the root canal system during
treatment, between appointments, or even after the conclusion of the endodontic
treatment.
– The most common reason being a breach of the aseptic chain during treatment.
– If the microorganisms that gain access to the root canal are successful in surviving into
and colonizing such a new environment, a secondary infection will establish itself and
may be one of the causes of postoperative pain.
35. Host resistance:
– Individuals who have reduced ability to cope with infections are more prone to develop
clinical symptoms after endodontic procedures in infected root canals. There are some
situations during the endodontic treatment that can facilitate microorganisms to cause
interappointment pain. These include:
• Apical extrusion of debris
• Incomplete chemomechanical preparation leading to changes in the endodontic
microbiota or in environmental conditions.
36. Non microbial causes/ operator related factors:
• Nonmicrobial causes are represented by chemical or physical factors that can inflict damage
to the periradicular tissues, and thereby can be responsible for the development of
interappointment pain.
• The intensity of pain will depend on several aspects, including intensity of the injury,
intensity of tissue damage, and intensity of the inflammatory response. All these three
phenomena are interconnected, as one is directly dependent on the other.
• Mechanical irritation causing periradicular inflammation includes mainly
overinstrumentation and overextended filling materials.
• Chemical irritation includes apical extrusion of irrigants or intracanal medications.
37. • Re-instrumentation
• Cortical trephination
• Incision and drainage (I and D)
• Intracanal medicaments
• Occlusal reduction.
• Drugs
Treatment :
38. Re-instrumentation:
– Definitive treatment may involve reentering the symptomatic tooth. The access cavity
should then be opened.
– Working lengths should be reconfirmed, patency to the apical foramen obtained and a
thorough debridement with copious irrigation performed. Remaining tissue,
microorganisms, and toxic products or their extrusion are arguably the major elements
responsible for the posttreatment symptoms. Drainage will allow for the exudative
components to be released from the periradicular tissues, thus reducing localized tissue
pressure.
39. Cortical trephination:
– Cortical trephination is defined as “the surgical perforation of the alveolar bone in an
attempt to release accumulated periradicular tissue exudates.”
– Various studies have evaluated the effectiveness of cortical trephination to prevent and
relieve posttreatment pain.
– Chestner et al. reported pain relief in patients with severe periradicular pain when
cortical trephination was performed.
40. Incision and drainage (I and D):
– The rationale for an I and D procedure is to facilitate the evacuation of pus,
microorganisms, and toxic products from the periradicular tissues.
– Moreover, it allows for the decompression of the associated increased periradicular
tissue pressure and provides significant pain relief.
– In teeth where the endodontic treatment has not yet been completed, it may be advisable
to re-enter the root canal system.
41. – If the abscess occurs after the obturation of the root canal system, incision of the
fluctuant tissue is perhaps the only reasonable emergency treatment, provided the root
canal filling is adequate.
– Antibiotics are usually not indicated in cases of a localized abscess, but they can be used
to supplement clinical procedures in cases where there is poor drainage and if the patient
has a concomitant trismus, cellulitis, fever, or lymphadenopathy.
– In addition, aggressive incision for drainage has been advocated for any infection with
acellulitis, regardless of whether it is fluctuant or indurated.
42. Intracanal medicaments:
– Clinical studies have demonstrated that posttreatment pain is neither prevented nor
relieved by medicaments such as formocresol, camphorated paramonochlorophenol,
eugenol, iodine potassium iodide, Ledermix, or calcium hydroxide
– However, the use of intracanal steroids, nonsteriodal antiinflammatory drugs
(NSAIDs),or a corticosteroid–antibiotic compound has been shown to reduce
posttreatment pain.
– In a study conducted by Walton et al. steroids and NSAIDs, when placed within the root
canal system after debridement procedures, can reduce or prevent post-treatment pain.
43. Occlusal reduction:
– There appears to be minimal agreement in the dental literature as to the benefit of
reducing the occlusion to prevent postendodontic pain.
– Rosenburg et al. demonstrated that in teeth with pain upon biting, occlusal reduction
was effective in reducing postoperative pain. Sensitivity to biting and chewing is perhaps
due to increased levels of inflammatory mediators that stimulate periradicular
nociceptors. Occlusal reduction may therefore prevent the continued mechanical
stimulation of the sensitized nociceptors
44. Drugs:
Antibiotics
– In a review on the use of systemic antibiotics for the control of post-treatment endodontic
pain, Fouad concluded that their use is without justification.
– Current advances in understanding of the biology of the infectious and inflammatory
process, along with the known risks associated with antibiotics, such as the emergence of
multiresistant bacterial strains, strongly indicate that the clinician should seriously
reevaluate their prescribing antibiotics.
45. Nonnarcotic analgesics
– The NSAIDs have been shown to be very effective for managing pulpal and periradicular
pain.
– In patients with known sensitivity to NSAIDs or aspirin, and in those who have
gastrointestinal ulcerations or hypertension due to renal effects of NSAIDs,
acetaminophen should be considered for post-treatment pain.
– Administration of NSAIDs alone is usually sufficient for most endodontic pain for
patients who can tolerate this drug class.
– The combination of an NSAID and acetaminophen, taken together, shows additive
analgesia for treating dental pain.
46. – If pain is not controlled by NSAIDs and acetaminophen, narcotic analgesics are required.
These may be given in combination with NSAIDs for additive effects
– The results demonstrate that the combination of ibuprofen with acetaminophen may be
more effective than ibuprofen alone for the management of postoperative endodontic
pain.
The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a
combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled
study. International Endodontic Journal, 37, 531–541, 2004
48. • Post-operative pain is a frequent complication associated with root canal treatment with a
reported incidence ranging between 3–58% (Sathorn et al. 2008).
• According to published data, pulp therapy and root canal treatment (RCT) induce more
frequent and more severe postoperative pain than do other dental operative procedures. In the
literature, reported frequencies of postendodontic pain (PEP) range from 1.5 to 53%
L. Levin, A. Amit, and M. Ashkenazi, “Post-operative pain and use of analgesic agents
following various dental procedures,” American Journal of Dentistry, vol. 19, no. 4, pp.
245–247, 2006.
49. – Although occurrence of pain is a multifactorial process, the underlying biological
mechanism involves development of acute inflammatory response in the periapical
tissues.
– It is a result of the interplay between physical (overinstrumentation, overextended
filling), chemical (extrusion of irrigants, medicaments and filling materials) or microbial
(apical extrusion of infected debris, changes in microbiota, secondary intraradicular
infections) factors that cause injury to periapical tissues (Torabinejad et al. 1988, Seltzer
& Naidorf 2004
50. The aetiological factors for postendodontic pain can be divided
into three categories:
Etiologies
Host related:
Gender,
Age,
Tooth type,
Immunological
status,
Psychological factors
Microbial causes:
Type of microbes,
Level of virulence,
Development of
ssecondary infection,
etc
Clinician related:
Missed canal,
Overinstrumentation,
Overobturation,
Incomplete
debridment. etc
52. – Studies have shown that factors such as preoperative pain, anxiety, tooth type, gender,
age, size of preoperative periapical lesion, single or multiple visit RCT, various
medications used, instrumentation and obturation techniques, vitality of tooth and
retreatment were significantly predictive for incidence of post-operative pain. Cases of
severe preoperative pain tend to develop more severe post endodontic discomfort in
comparison to mild or no preoperative pain.
53. • Evidence of literature of the effect of vitality of the pulp on incidence of post endodontic
pain remains inconclusive.
• In asymptomatic apical periodontitis, there is a balance between the infectious microflora
and host defence mechanisms of periapical tissues, which is referred to as local adaptation
syndrome (Seltzer & Naidorf 2004). During chemomechanical preparation, various irritants
such as dentinal debris, necrotic tissue, microbes or irrigant solutions from the root canal
may gain access to periapical tissues and disturb this balance to cause inflammation and post-
operative pain.
Vital vs non vital teeth:
Gotler M, Bar-Gil B, and Ashkenazi M. Postoperative Pain after Root Canal Treatment:
A Prospective Cohort Study. International Journal of Dentistry. Volume 2012, Article ID 310467
54. • RCT of teeth with vital pulp induced a significantly higher incidence and severity of PEP
(63.8%; 2.46 ± 1.4, resp.) than RCT of teeth with necrotic pulp (38.5%; 1.78 ± 1.2, resp.) or
of retreated teeth (48.8%; 1.89 ± 1.1, resp.)
• Bayram et al. (2009) No significant difference between vital and non-vital teeth (p>.01).
• Bhagwat and Mehta (2013) No significant difference between vital and non-vital teeth.
• But Mor et al. showed that flare-ups more often followed endodontic treatment in nonvital
teeth and after retreatment than in vital teeth.
55. – However Harrison et al. reported that the incidence and intensity of flare-up were
unrelated to tooth vitality. No correlation has been found between pulp status and any
PEP.
– The most recent study done by Sumita Bhagwat and Deepil Mehta (2013) showed that
within the limits of their study, single visit procedure for root canal preparation showed
encouraging results in vital and nonvital teeth with and without periapical radiolucency
and is definitely a promising treatment option in routine endodontics as the incidence of
pain appears to be distributed fairly evenly in all the groups.
Incidence of postoperative pain following single visit endodontics in vital and nonvital teeth: An
in vivo study. Contemp Clin Dent. 2013 JulSep; 4(3): 295–302
56. – Anthony DiRenzo, et al ( 2002) showed that there was no difference in postoperative
pain between patients treated in 1 appointment and patients treated in 2 appointments.
The majority of patients in both groups reported no pain or only minimal pain within 24
to 48 hours of treatment.
– Hameed A H et al in their study demonstrated that there was a low incidence of
postoperative pain after conventional RCT. No significant difference exists in
postoperative pain after singlevisit or multiplevisit RCT.
Abdel Hameed H. ElMubarak et al. Postoperative Pain in Multiple-visit and
Single-visit Root Cana Treatment. Journal of Endodontics Volume 36, Issue 1,
January 2010, Pages 36–39
Single visit vs multivisit:
57. – Rao et al. (2014) No difference in post operative pain between single/multiple visits.
– However, Two visit endodontic treatment with intracanal medication was found to be
effective in reducing postoperative pain of previously symptomatic teeth and decreased
the number of flareups in all retreatment cases.
Postoperative pain after endodontic retreatment: Single versus two visit treatment. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Volume 98, Issue 4,
October 2004, Pages 483–487
58. – Occlusal reduction should prevent postoperative pain in those patients whose teeth
initially exhibit pulp vitality, percussion sensitivity, preoperative pain, and/or the absence
of a periradicular radiolucency.
– But a recent study done by Parirokh M et al, (2013) contradicted the previous results. It
showed that occlusal surface reduction did not provide any further reduction in
postoperative pain for teeth with irreversible pulpitis and mild tenderness to percussion
compared with no occlusal reduction.
Paul A. Rosenberg, Peter J. Babick, Leon Schertzer, DDS , Anthony Leung. The effect of
occlusal reduction on pain after endodontic instrumentation. Journal of Endodontics
Volume 24, Issue 7, July 1998, Pages 492-496
Occlusion reduction
Effect of Occlusal Reduction on Postoperative Pain in Teeth with Irreversible
Pulpitis and Mild Tenderness to Percussion. Journal of Endodontics
Volume 39, Issue 1, January 2013, Pages 1–5
59. – The results of this prospective in vivo study suggest that a higher incidence of
postendodontic pain should be expected after manual root canal preparation. However a
second major finding of the study is that when present, postendo pain after a rotary canal
preparation is expected to last longer.
Rotary versus manual instrumentation:
Ana Ariasa et al. Prospective case controlled clinical study of postendodontic pain.
Journal of Dentistry Volume 43, Issue 3, March 2015, Pages 389–395
60. – A statistical analysis of pain data from 195 cases showed that the use or type of
intracanal medicament did no alter the frequency of flare-ups. Hence there was no
difference in the flare-up rates at 4 h or 24 h between Ledermix, calcium hydroxide or no
dressing.
Intracanal medicament:
Ernest H. Ehrmann; Harold H. Messer; and Robert M. Clark. Flare-ups in endodontics and their
relationship to various medicaments. Aust Endod J 2007; 33: 119–130
61. – Nonsteroidal antiinflammatory drugs (NSAIDs) have a well established analgesic
efficacy for inflammatory pain. These drugs exert their effect by inhibiting the enzyme
cyclooxygenase (COX) and are commonly used for the management of pain after
endodontic treatment.
– In a study by Elizabeth et al, they identified genetic variants in COX2 (haplotype
composed of rs2383515 G, rs5277 G, rs5275 T, and rs2206593 A) associated with post-
treatment pain after endodontic treatment.
Elizabeth Applebaum, Andrea G. Nackley, Eric Bair, William Maixner, Asma A. Khan. Genetic
Variants in Cyclooxygenase2 Contribute to Posttreatment Pain among Endodontic Patients.
Journal of Endodontics Volume 41, Issue 8, August 2015, Pages 1214–1218
Gentic variation and its influence on
postendodontic pain
62. – Al Negrish and Habahbeh (2006) demonstrated in their study that incidence of post
endodontic pain in females (6%),males (3%).
– Salma and Khurshiduzzaman (2013) published that incidence of post endodontic pain in
females (10%), males (6.7%)
– Analysis of the influence of patient's age, gender, arch, vitality of the tooth, and presence
of preoperative pain, on prevalence of the postoperative pain showed that it is higher in
the old age group ( 41-65 years), women, mandibular teeth, and with presence of
preoperative pain.
Syed Gufran Ali, Sanjyot Mulay, Aparna Palekar, Deepak Sejpal, Anurag Joshi, and Hina Gufran. Prevalence of and factors
affecting post-obturation pain following single visit root canal treatment in Indian population: A prospective, randomized
clinical trial. Contemp Clin Dent. 2012 OctDec; 3(4): 459–463.
Age, Gender, Arch:
63. • Irrigation with ultrasonics and endovac show less incidence of postendo pain pain when
compared to conventional irrigation with needle.
• A study by mitchell R P, et al showed significantly less extrusion risk using the
EndoVac system compared
Irrigation technique
Ross Paton Mitchell, SungEun Yang, J. Craig Baumgartner. Comparison of Apical Extrusion of
NaOCl Using the EndoVac or Needle Irrigation of Root Canals. Journal of Endodontics
Volume 36, Issue 2, February 2010, Pages 338–341
64. – Márcia et al( 2009) concluded that preoperative single oral dose of dexamethasone (4
mg) substantially reduced postendodontic pain.
– T Seyed Mohsen Jalalzadeh, et al (2010) in their study suggested that a preoperative,
single oral dose of prednisolone ( 30 mg) substantially reduced postendodontic pain.
– A recent study (2015) suggested that a preoperative administration of Dexamethasone(4
mg) resulted in significant less post-operative endodontic pain at all time-intervals.
Preoperative oral administration of Dexamethasone performed best in reducing pain post
operatively.
Effect of premedication
Namrata Sharma,Vineeta Nikhil, Sachin Gupta. Effect of preoperative administration of steroid
with different routes on post endodontic pain: a randomized placebo controlled clinical trial.
Endodontology Volume: 27 Issue 2 December 2015
65. – Hakan et al. (2011) A prophylactic single dose of 20 mg tenoxicam significantly
reduced the post operative pain
– Priyank et al. (2014) Single dose of 10mg ketorolac and 100mg tapentadol as
pretreatmemt analgesic reduced the post endodontic pain.
– Postendodontic pain was substantially reduced by preoperative administration of single
oral dose of diclofenac sodium( 100 mg). It is thus possible to conclude that these
favorable results might help to prevent postendodontic pain, especially in patients with a
low pain threshold.
Metri M, Hegde S, Bhandi S. Effect of pretreatment diclofenac sodium on
postendodontic pain: A randomised controlled trial. J Conserv Dent 2016;19:7-10.
66. – In the past, several attempts have been made to find whether there exists a correlation
between preoperative pain and post endodontic pain.
– It can be concluded that there is a strong positive correlation between preoperative and
post endodontic pain or post obturation pain. This finding could be explained by the
presence of pretreatment infection, which can lead to secondarily infected during
treatment (Risso et al., 2008).
– Durre and Muhammad (2014) showed that Patients with preoperative pain had more
(83.3%) post operative pain
Preoperative/pre-obturation pain
67. • There have been studies on the incidence of post endodontic pain by the type of teeth treated,
whether anterior, premolar or molar.
• In general, incidence of post operative pain was higher in mandibular teeth as compared to
maxillary teeth. This variation might be due to the reason that mandible has a dense trabeculae
pattern, which causes reduced blood flow and localization of infection leading to delayed
healing patterns (Syed et al., 2012). This difference may be also explained due to the greater
number of canals and complex root canal morphology apically (Watkins et al., 2002; Cleghorn
et al., 2006).
• In comparison of premolar teeth with anterior teeth, it was found out that theta higher incidence
of pain was for premolars due to the higher prevalence of missed canal and variation in the
apical canal anatomy.
Type of teeth
68. – Salem et al. (2009) 115 Step down technique had less post operative pain than step back
technique
– Step down or crown down technique produce less incidence of post endodontic pain
when compared with step back technique. This may be due to the reason that step back
technique; there is a high chance of pushing the debris beyond the apical foramen as
stated in different studies (Ruiz et al., 1987; Al Omari and Dummer, 1995). In the step
down technique, the bulk of tissue debris and microorganisms are removed before apical
instrumentation is commenced, which greatly reduces the risks of extrusion causing
periapical inflammation (Carrotte, 2004).
Instrumentation technique:
Shibu Thomas Mathew. Post operative pain in endodontics: A systemic review.
Journal of Dentistry and Oral Hygiene. Vol. 7(8), pp. 130-137, August 2015
69. – Postoperative pain in patients who treated under general anesthesia was significantly less
than the patients who treated under local anesthesia.
– Al-Kahtani (2014) Long acting anesthetic like bupivacaine can cause less post operative
pain than lidocaine
Feizi Ghader, Kaviani Naser, Mehrparvar Roza, Binandeh Elham Sadaat, Tabrizizadeh
Mehdi , Saatchi Masoud. A comparative study of pain following endodontic treatment
under general anesthesia. Journal of Dental Medicine. 2015, 27(4): 247-253
Local anesthesis versus
general anesthesia
70. • 25%–40% of all endodontic cases have been described to suffer from post-treatment pain
• Prevention and management of post-endodontic pain (PEP) is an integral part of endodontic
treatment. Informing patients about expected post-endodontic pain (PEP) and prescribing
medications to manage it can increase patient confidence in their dentists, increase patients’
pain threshold, and improve their attitude toward future dental treatment.
• Management of postendodontic involves all those measures suggested to manage
interappoint appointment pain. Along with previously mentioned measures, retreatment of
the involved tooth could be considered.
Post operative pain managment
71. – It is concluded that postobturation pain is likely to occur in first 24 h which further
reduces as time passes. Thus, it is a strong indication that clinician should not overreact
to early postobturation pain by immediately initiating endodontic re-treatment procedures
or extraction of the involved tooth.
72. • Even though it has been demonstrated that a endodontic pain has no significant influence on
the outcome of endodontic treatment, its occurrence is extremely undesirable for both the
patient and the clinician, and can undermine clinician–patient relationships. Therefore,
clinicians should employ proper measures and follow appropriate guidelines in an attempt to
prevent the development of inter-appointment or post-endodontic pain.
– But occurrence of mild to moderate type of pain can occur even after rendering treatment
of the highest standards.
• Importantly time is an important factor to be consider in post endodontic pain. So, the
dentist should not be over anxious or over react to an incidence of post endodontic pain and
immediately initiate with retreatment or extraction.
Conclusion:
73. References:
• Pathways of the pulp. Cohen
• Grossmen’s endodontics
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steroid with different routes on post endodontic pain: a randomized placebo controlled
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