The clinical toxicity of endodontic medicaments

Predicting severe pain after root canal therapy in the National Dental PBRN

Some patients experience severe pain following root canal therapy (RCT) despite advancements in care. We sought to identify factors, which can be measured preoperatively, that predict this negative outcome so that future research may focus on preemptive steps to reduce postoperative pain intensity. Sixty-two practitioners (46 general dentists and 16 endodontists) who are members of the National Dental Practice-Based Research Network enrolled patients receiving RCT for this prospective observational study. Baseline data collected from patients and dentists were obtained before treatment. Severe postoperative pain was defined based on a rating of ≥7 on a scale from 0 (no pain) to 10 (pain as bad as can be) for the worst pain intensity experienced during the preceding week, and this was collected 1 wk after treatment. Multiple logistic regression analyses were used to develop and validate the model. A total of 708 patients were enrolled during a 6-m period. Pain intensity data were collected 1 wk postoperatively from 652 patients (92.1%), with 19.5% (n = 127) reporting severe pain. In multivariable modeling, baseline factors predicting severe postoperative pain included current pain intensity (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07 to 1.25; P = 0.0003), number of days in the past week that the subject was kept from their usual activities due to pain (OR, 1.32; 95% CI, 1.13 to 1.55; P = 0.0005), pain made worse by stress (OR, 2.55; 95% CI, 1.22 to 5.35; P = 0.0130), and a diagnosis of symptomatic apical periodontitis (OR, 1.63; 95% CI, 1.01 to 2.64; P = 0.0452). Among the factors that did not contribute to predicting severe postoperative pain were the dentist's specialty training, the patient's age and sex, the type of tooth, the presence of swelling, or other pulpal and apical endodontic diagnoses. Factors measured preoperatively were found to predict severe postoperative pain following RCT. Practitioners could use this information to better inform patients about RCT outcomes and possibly use different treatment strategies to manage their patients (Clinicaltrials.gov NCT01201681).

Flare-ups in Endodontics: II. Therapeutic Measures

Various treatment regimens for the relief of pain during endodontic therapy, including relief of occlusion, pre-medication, establishment of drainage, and intracanal and systemic medications are presented. In addition, the rationale for the use of placebos is discussed.

Interappointment emergencies in teeth with necrotic pulps

The incidence of interappointment emergencies in symptomatic and asymptomatic teeth with necrotic pulps was evaluated, and severity of flare-ups was determined by a quantitative method using a flare-up index. There were no significant differences in the incidence of flare-ups attributable to gender, age, diameter of lesion, taking analgesics, placebos, or no medication, or preoperative symptomatic or asymptomatic tooth diagnoses (p > 0.05). There were significantly more painful flare-ups in mandibular teeth than in maxillary (p < 0.05).

In vitro evaluation of the effectiveness of calcium hydroxide and paramonochlorophenol on anaerobic bacteria from the root canal

The effectiveness of calcium hydroxide and paramonochlorophenol (PMCP) was tested on anaerobic bacteria isolated from infected root canals, at time intervals 5, 15, 30 and 60 min. The experimental method used was similar to that proposed by the German Society of Hygiene and Microbiology (DGHM), with slight modifications. Testing revealed that calcium hydroxide was significantly more effective than PMCP against the total number of anaerobes. Additionally, it was proved to be quickly and highly effective against some microorganisms related to severe clinical symptoms, such as B. melaninogenicus and P. gingivalis, as well as against actinomyces species.

The role of intracanal medication in root canal treatment

The role of intracanal medication as a root canal dressing is re-examined. In pulpectomy and some root canal treatments, where the root canal contains vital pulp tissue, it is doubtful whether a routine intracanal medicament is needed. In infected root canals, intracanal medication has been advocated for many purposes. An intracanal medicament is used to: (i) eliminate any remaining bacteria after canal instrumentation; (ii) reduce inflammation of periapical tissues and pulp remnants; (iii) render canal contents inert and neutralize tissue debris; (iv) act as a barrier against leakage from the temporary filling; (v) help to dry persistently wet canals. However, most of the indications for intracanal medicaments are questionable. Intracanal medicaments should only be used for root canal disinfection as part of controlled asepsis in infected root canals, and their role is secondary to cleaning and shaping of the root canal. Thorough canal debridement and adequate canal preparation are more pertinent, and their importance is emphasized. Bacteriological sampling may be necessary if a tooth does not respond to treatment, to help in the choice of intracanal medicament.

Relationship of intracanal medicaments to endodontic flare-ups

The purpose of the study was to compare the effect of three intracanal medicaments on the incidence of post-instrumentation flare-ups. All teeth were instrumented to a predetermined minimum size using a 0.5% solution of sodium hypochlorite as the irrigant. Formocresol, Ledermix, and calcium hydroxide were placed in strict sequence irrespective of the presence or absence of symptoms or radiographic signs of apical periodontitis. The patients were given written post-operative instructions and a prescription for 600 mg ibuprofen to be taken if mild to moderate pain developed. If severe pain and/or swelling developed the patient was instructed to call the office immediately and was considered to have had a flare-up. Twelve flare-ups occurred in teeth with radiographic signs of apical periodontitis; none in teeth without periapical radiolucencies. Six of the twelve flare-ups occurred in retreatment cases and the other six occurred in teeth without previous endodontic treatment. No significant difference was found in the flare-up rate among the three intracanal medicaments.

Management of endodontic pain with nonsteroidal anti-inflammatory agents: a double-blind, placebo-controlled study

The ability of two nonsteroidal anti-inflammatory agents--piroxicam and diclofenac--to control endodontic pain was compared with that of a placebo control in a double-blind study of 267 patients requiring endodontic therapy. Endodontic treatment was carried out over three visits with an interval of 5 to 7 days between each two consecutive visits. All patients were clearly instructed to take the medication only if they experienced pain, between the visits or postoperatively, for 3 consecutive days. The patients subjectively rated their pain on a scale of 1 to 4 as none, mild, moderate, or severe. The ratings were done preoperatively and at 2, 4 and 8 hours after the initial dose of medication was taken, as well as on the second and third days. Statistical analysis of the data revealed that both piroxicam and diclofenac significantly reduced the mean pain score at the end of all observations and were significantly superior to the placebo until the end of the study. More than 90% of the patients treated with piroxicam and more than 80% of the patients treated with diclofenac showed complete relief of pain. Overall, piroxicam was clearly more effective than diclofenac or the placebo. It provided more consistent relief of pain, beginning 2 hours after the initial dose, and it continued to do so at every interval thereafter. Diclofenac required longer time to reach maximum effectiveness. Piroxicam's superiority was greater at the first and second days after the initial dose of medication was taken. With respect to side effects, piroxicam was better tolerated by the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and laboratory assessments of camphorated monochlorophenol in endodontic therapy

The purpose of this study was to evaluate the effect of camphorated monochlorophenol (CMCP) on bacterial status of root canals of nonvital teeth during treatments. The presence of bacteria in 15 single-rooted teeth with periapical lesions was studied throughout a whole period of treatment. Patients were randomly divided into three groups. In group 1, a control group, the intracanal medication was omitted. The teeth were enlarged under aseptic conditions in combination with the use of 3% H2O2 and 5.25% NaOCl as irrigants. In group 2, after chemomechanical preparation, the root canals were dressed with 2 microliter of 40% CMCP. The medicament was replaced on days 3 and 7. In group 3, root canals were treated in a manner similar to those in group 2, except that the medicament was renewed on days 1 and 7. The loss of CMCP was determined in groups 2 and 3. The results showed that chemomechanical preparation could reduce bacteria in root canals to an uncultivable number. Approximately 62.5% of the original concentration of CMCP was lost after placement in root canals for 1 day. Intracanal dressing with CMCP between appointments induced a rapid decrease in number of bacteria in root canals within the first 1 to 3 days. However, compared to chemomechanical preparation, the antimicrobial effect of CMCP was not clinically impressive because negative cultures also could be observed despite the absence of intracanal medications.

Effect of occlusal relief on endodontic pain

It has been suggested that removal of occlusion contacts will prevent or reduce postoperative endodontic pain during treatment. However, this theory has not been tested in clinical experiments. In this study, after endodontic instrumentation, the treated posterior tooth randomly received occlusal relief or mock-occlusal relief. Mean pain levels and the incidence of pain to occlusal pressure at various time intervals were recorded on questionnaire postcards by all patients, as was the duration of discomfort. Comparison of pain experienced by the occlusal treatment groups through statistical analysis gave the following conclusions: Spontaneous pain levels in the mock-occlusal relief and occlusal relief groups were not significantly different; Spontaneous pain levels in the mock-occlusal relief and occlusal relief groups did significantly relate to preoperative pain; Pain incidence from occlusal pressure in the mock-occlusal relief and occlusal relief groups did not significantly differ; Pain from occlusal pressure in both occlusal treatment groups did not significantly relate to preoperative pain; Duration of discomfort was not related to the occlusal treatment provided. The theory may be invalid that prophylactic removal of occlusal contacts is a pain preventive measure.