Effect of Preoperative Corticosteroids in Patients with Symptomatic Pulpitis on Postoperative Pain after Single-visit Root Canal Treatment: A Systematic Review and Meta-analysis

Patient-related predictors of post-operative pain following root canal treatment: A structural model analysis

AIM

The pathways to post-operative pain are complex and encompass factors that extend beyond the treatment protocol employed. This study aimed to identify patient-related predictors of post-operative pain following root canal treatment.

METHODOLOGY

A total of 154 patients received a single-visit root canal treatment for asymptomatic necrotic mandibular molars. Before treatment, dental anxiety, dental fear and sense of coherence (SOC) were measured as predictors for each patient using validated questionnaires. Other measured predictors included gender, age, previous negative experiences at the dental offices and prior root canal treatment. Post-operative pain was assessed using the Numeric Rating Scale at multiple time-points over 30 days. Structural equation analysis was employed to evaluate the direct and indirect effects of patient-related predictors on a theoretical model of post-operative pain. The irrigant solution was also included in the model, as it was the only aspect that varied in the treatment protocol (sodium hypochlorite 2.5% and 8.25%).

RESULTS

Dental anxiety (coefficient 0.028; p < .01), dental fear (coefficient 0.007; p = .02) and irrigant solution (coefficient 0.004; p = .03) exerted a direct effect on post-operative pain. SOC exerted an indirect effect on post-operative (coefficient 0.006; p = .01) through dental anxiety and dental fear. Moreover, previous negative experiences (coefficient 0.048; p = .04) exerted an indirect effect on post-operative pain through dental anxiety.

CONCLUSIONS

Dental anxiety, dental fear, previous negative experiences and SOC are patient-related predictors of post-operative pain following root canal treatment. These factors should be taken into consideration in clinical practice, as patients with these characteristics may be at an increased risk of experiencing post-operative pain.

Comparison of Bromelain and Diclofenac in the Management of Postoperative Pain and Quality of Life Following Root Canal Therapy: A Randomized Controlled Trial

Aim This study aimed to compare the analgesic efficacy and adverse effects of oral bromelain and diclofenac in relieving postoperative pain and improving postoperative quality of life in patients with irreversible pulpitis in mandibular first molars after root canal therapy. Materials and methods A simple randomized double-blinded clinical trial was carried out. One hundred patients with symptomatic pulpitis requiring root canal therapy of mandibular first permanent molars were randomly divided into two groups after obtaining informed consent. After access opening, preparation of the root canal and temporization, Group I (n=50) patients received oral bromelain 200 mg and Group II (n=50) received oral diclofenac sodium 50 mg, respectively. The patients were asked to rate their pain on a visual analog pain intensity scale (VAS) and rate their quality of life using the postoperative quality of life (POQoL) questionnaire after 6, 12, 24, 48, and 72 hours. Results Bromelain and diclofenac were equally effective for postoperative analgesia, but diclofenac showed immediate pain relief and improved quality of life at 6 hours. After 12 hours bromelain showed similar effects in managing pain and postoperative quality of life with less adverse effects. Conclusions When compared to diclofenac, bromelain has the same analgesic efficacy after 12 hours but a lower risk of adverse effects in patients receiving root canal therapy for postoperative pain. Diclofenac is more effective in immediate postoperative pain relief and improvement in quality of life for patients with moderate to severe pain.

Influence of Diclofenac Potassium versus Prednisolone on Postendodontic Pain and Pulpal Interleukin-8 Expression in Symptomatic Irreversible Pulpitis Cases: A Randomized Placebo-controlled Trial

AIM

This prospective, randomized, double-blind clinical trial investigated the impact of diclofenac potassium, prednisolone, and placebo as oral premedication on postendodontic pain and pulpal interleukin (IL)-8 expression in patients with irreversible pulpitis.

METHODS

Thirty-six patients undergoing conventional endodontic treatment were assigned into one of 3 groups (n = 12). Pulpal blood samples were taken after access cavity preparation and stored until they were analyzed using enzyme-linked immunosorbent asssay for quantification of IL-8. Postendodontic pain was scored using the visual analogue scale. Outcome data were statistically analyzed using one-way analysis of variance, Kruskal-Wallis, Friedman's, Dunn's, Chi-square, and Fisher's exact tests and Spearman's correlation coefficient. The significance level (α) was set at 0.05.

RESULTS

Apart from preoperative pain scores, all groups had similar baseline characteristics (P > .05). Immediate postendodontic pain scores had a significant difference between all groups (P < .05) where placebo group showed the highest score. There was no significant difference between all groups at 6 and 12 hours postoperatively (P > .05). Furthermore, there was no significant difference in the incidence of postendodontic pain and in mean IL-8 levels between the 3 groups (P > .05).

CONCLUSIONS

The only impact the premedications had was on the immediate postendodontic pain intensity, and they had no influence on the later time points, incidence of postendodontic pain or pulpal IL-8 levels.

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.

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

AIM

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

Comparison of ultrasonic versus side-vented needle irrigation for reductions in bacterial growth and postoperative pain: A randomized controlled trial

Background

Postoperative pain affects 16%-25% of root canal therapy patients. The irrigating system and irrigants used should reduce bacterial load without irrigant extrusion beyond the root canal apex, potentially reducing postoperative pain and discomfort.

Aim

This study aims to compare the effects of passive ultrasonic irrigation and side-vented needle irrigation on postoperative pain and bacterial load in single-rooted teeth with pulp necrosis.

Materials and Methods

Eighty patients with pulpal necrosis in single-rooted teeth were randomly categorized into two groups (n = 40 each): Group A (side-vented needle irrigation) and Group B (passive ultrasonic irrigation). Bacterial samples were collected using sterile paper points after initial access cavity preparation (S1) and standard endodontic instrumentation + irrigation (S2). Bacterial growth was assessed on MacConkey and blood agar. Pain was recorded 30 min preoperatively and 6, 12, 24, and 48 h postoperatively.

Statistical Analysis Used

Chi-square test, independent t-test and paired t-test.

Results

Irrigation with Irrisafe tips showed increased number of bacteria-free samples and a significant reduction in postoperative pain (at the 6 and 12 h time-points) when compared to side-vented needle.

Conclusions

Passive ultrasonic irrigation with Irrisafe tips may be more effective than side-vented needle irrigation in reducing postoperative pain and intracanal bacterial load in patients undergoing endodontic treatment.

Acupuncture for Management of Endodontic Emergencies: a Review

Root canal treatment (RCT) employed for painful endodontic conditions like apical periodontitis and irreversible pulpitis is associated with a high incidence of postoperative pain. Pharmacological management for this purpose is effective, but not entirely free from side effects and in some cases may fail to provide adequate relief. Furthermore, concerns have been raised regarding the transmission of coronavirus disease-2019 (COVID-19) as a result of the aerosols generated and prolonged chair side time required for RCT. Acupuncture is a traditional Chinese therapy commonly employed as an alternative for the treatment of pain. And what's more, the use of acupuncture has been recently reported as treatment for the management of endodontic pain as well as on the anesthetic success in patients with irreversible pulpitis. This review aims to evaluate the current evidence for acupuncture in endodontics and its potential role in emergency pain relief and management for patients. To combat this, a thorough search for literature within the field was performed in five electronic databases. Retrieved studies were screened according to the pre-defined eligibility criteria. After both an electronic and manual search, five studies were selected for review. These studies reported the beneficial effects of acupuncture in reducing the failure of nerve block in patients with irreversible pulpitis and in controlling both intraoperative and postoperative pain following RCT. In addition, it was also reported to reduce anxiety surrounding the dental procedure and minimized the intake of analgesics after the endodontic procedure, which can result in some unwanted side effects. However, more in depth clinical research is required before any recommendation regarding the application of acupuncture in endodontic patients can be made.

Outcomes reporting in systematic reviews on non-surgical root canal treatment: A scoping review for the development of a core outcome set

BACKGROUND

Studies related to non-surgical root canal treatment are amongst the most frequently performed clinical studies in endodontics. However, heterogeneity in reporting outcomes and lack of standardization is a significant challenge to evidence synthesis and guideline development.

OBJECTIVES

The aims of the present scoping review were to (a) identify outcomes reported in systematic reviews evaluating non-surgical root canal treatment; (b) identify how and when the reported outcomes were measured; (c) assess possible selective reporting bias in the included studies. The information obtained in this study should inform the development of a core outcome set (COS) for non-surgical root canal treatment.

METHODOLOGY

Structured literature searches were performed to identify systematic reviews on non-surgical root canal treatments published in English between January 1990 and December 2020. Two reviewers undertook study selection and data extraction. Outcomes were categorized according to a healthcare taxonomy into five core areas (survival, clinical/physiological changes, life impact, resource use, and adverse events). The outcome measurement tools and length of follow-up were recorded.

RESULTS

Seventy-five systematic reviews were included, of which 40 included meta-analyses. Most reviews reported on physiological and clinical outcomes, primarily pain and/or radiographic assessment of periapical status, and a variety of measurement tools and scales were used. Few reviews focused on tooth survival, life impact, resources, and adverse events. The heterogeneity amongst the reviews was large on all parameters. Less than 40% of the reviews assessed the risk of selective reporting.

DISCUSSION

Overall aims of the included reviews were highly heterogenic; thus, outcomes and how they were measured also varied considerably. Patient-centred outcomes and the use of resources were rarely reported on.

CONCLUSIONS

Most studies reported on physiological and clinical outcomes, in particular pain and/or radiographic healing. Measurement tools, scales, thresholds, and follow-up periods varied greatly within each outcome, making comparison across studies complicated. Less than 40% of the reviews assessed risk of selective reporting; thus, selective bias could not be ruled out. The presented information on reported outcomes, measurement tools and scales, and length of follow-up may guide the planning of future research and inform the development of a COS for non-surgical root canal treatment.

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.

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.

Predicting postoperative pain following root canal treatment by using artificial neural network evaluation

This study aimed to evaluate the accuracy of back propagation (BP) artificial neural network model for predicting postoperative pain following root canal treatment (RCT). The BP neural network model was developed using MATLAB 7.0 neural network toolbox, and the functional projective relationship was established between the 13 parameters (including the personal, inflammatory reaction, operative procedure factors) and postoperative pain of the patient after RCT. This neural network model was trained and tested based on data from 300 patients who underwent RCT. Among these cases, 210, 45 and 45 were allocated as the training, data validation and test samples, respectively, to assess the accuracy of prediction. In this present study, the accuracy of this BP neural network model was 95.60% for the prediction of postoperative pain following RCT. To conclude, the BP network model could be used to predict postoperative pain following RCT and showed clinical feasibility and application value.

Therapeutic effect of one-time root canal treatment for irreversible pulpitis

Objective

To compare the therapeutic effects of one-time root canal treatment versus two-time treatment in patients with irreversible pulpitis.

Methods

We classified 130 patients into a one-time treatment group (group A; n = 68) and a two-time treatment group (group B; n = 62) according to the number of patient visits. Clinical efficacy at 6 months and 1 year follow-ups as well as serum levels of interleukin-6, tumor necrosis factor alpha, and high-sensitivity C-reactive protein before and 1 week after endodontic treatment were observed. Additionally, the level of treatment satisfaction between the two groups was compared, and the degree of pain was evaluated using the visual analogue scale.

Result

One week after treatment, serum interleukin-6, tumor necrosis factor alpha, and high-sensitivity C-reactive protein levels were significantly decreased in the two groups; however, levels in group B were significantly lower than those in group A. Additionally, visual analogue scale scores of patients in group A were significantly higher than those of patients in group B.

Conclusion

One-time root canal therapy can effectively improve postoperative pain and the expression of inflammatory factors in the serum of patients undergoing treatment.