History of Endodontics aae/abe

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What is the incidence of Post-obturation pain?

  1. Baumgartner/Svec 1983Risk factor for post obturation pain was extrusion of sealer or gutta-percha. No relationship with vitality, PARL, root # or level of obturation. Pain rate w/in first 24 hrs. = 47.6% (14% severe)

  2. Ng IEJ 2004 – NSRCT or Retx, Prevalence: 40.2% (<12% Severe). Predictors: Females, Post-preparation pain, Post-preparation swelling, Single visit, Molars, < 3mm PARLs

  3. Figini Cochrane Review – More Post-op pain w/ Single visit

Would you leave a tooth open to drain?


  1. August – Necrotic teeth left open to drain were filed and closed with minimal flare-ups.


  1. Bence – Avoid leaving teeth open to prevent flare-ups when reclosing.

  1. Simon – described oral pulse granuloma due to legumes.

  1. Weine – When access is left open, a greater number of appointments were needed to complete treatment and more flare-ups occurred than when the tooth was kept sealed. “If you file, don’t close, if you close don’t file”

Is routine trephination required?


  1. Moos Pulpectomy alone provided significantly better postoperative pain relief at 4 hours compared with pulpectomy /trephination. At no time interval did the trephination group have less pain than the group without trephination.

  1. Nist/Reader - Trephination did NOT significantly decrease pain, percussion pain, swelling, or # of ibuprofen. It was therefore determined not to be routinely recommended for symptomatic necrotic teeth with radiolucencies.

  1. Houck/Reader – Short-term drainage upon access in symptomatic necrotic teeth with periapical radiolucencies did NOT reduce pain, percussion pain, swelling or the number of analgesic tablets taken compared to teeth that did not drain.

Does reducing the occlusion decrease post-op pain?


  1. Rosenberg 2009 – LOE 1- Random assignment. 48 hour VAS. Occlusal reduction reduced postoperative pain in those patients whose teeth initially exhibited pulp vitality, percussion sensitivity, preoperative pain and/or the absence of a periradicular radiolucency. Post-instrumentation.


  1. Parirokh 2012 – LOE 1 – Random assigment. 6 hrs – 6 days VAS. Sym. Irreversible Pulpitis patients with Percussion sensitivity. Occlusal reduction did NOT significantly reduce pain levels in comparsion to placebo group. Both groups had signficant  pain post-instrumentation/CaOH2.

  1. Holland – Preoperative pain did not influence the effectiveness of occlusal reduction. In fact occlusal reduction did not impact post operative pain.

  1. Walton – Prophylactic occlusal reduction did not decrease post operative pain; relieve occlusion only as needed. Pre-op pain was related to post-op pain.

Pain Management

Analgesic Strategy for post-op pain

  1. Ibuprofen alone (pre-op admin/post-op pain)

    1. Dionne 1983 (NIH/VCU) – 3rd molar exts - Pre-op: Ibu 800 mg sig. more effective than Aceto 600 mg for  post-op pain; Post-op: Ibu 400 mg sig. more effective than Aceto 600 mg or Aceto 600 mg + Codeine 60 mg for  post op pain

    2. Menke/Jackson 2000NSRCTPre-op: Ibu 600 mg sig. more effective than Etodolac 400 mg or Placebo for  post-op pain at 4 and 8 hours post NSCRT (37/42 1 visit)

  1. Ibuprofen + Acetominophen (post-op admin/post-op pain)

    1. Brevik 1999 – 3rd molar exts – Post-op: Diclofenac (NSAID) 100 mg + Aceto 1 g sig. more effective than Diclofenac 100 mg or Aceto 1 g or Aceto 1 g + Codeine 60 mg at  post-op pain intesity

    2. Menhinick/Gutmann 2004NSRCTPost-op: Ibu 600 mg + Aceto 1000 mg sig. more effective than Ibu 600 mg only or placebo at  post-op pain intensity from 0-8 hours post NSRCT (1 visit) w/ pre-op mod-severe pain

Pain Management Regimens (Hargreaves)

Flexible strategies for pain management; See Oxford League Table

Max dosages: Ibuprofen: 3200 mg/day, Acetominophen: 3000 mg/day

  1. Aspirin-like drugs indicated (every 8 hours):

    1. Mild pain: 200-400 mg Ibuprofen

    2. Moderate pain: 600-800 mg Ibuprofen or 600 mg Ibuprofen + 1000 mg Acetominophen (Menhinick)

    3. Severe pain: 600 mg Ibuprofen + Acetominophen/Opiate (up to 10 mg oxycodone)

  1. Aspirin-like drugs contra-indicated (every 8 hours):

    1. Mild pain: 650-1000 mg Acetominophen

    2. Moderate pain: 650-1000 mg Acetominophen + Opiate (up to 60 mg Codeine)

    3. Severe pain: 1000 mg Acetominophen + Opiate (up to 10 mg oxycodone)

Pre-op Analgesics & Anesthesia

YES (all LOE 1 studies)

  1. Parirokh 2010 - 150 pts w/ Sym. Irreversible Pulpitis, IAN B Success: 600 mg Ibuprofen 78%, Indomethacin 62%, Placebo 32% - Preop (1 hr) Ibu & Indo Signficantly  Success of IAN B in Symptomatic IP patients

  2. Ianiro/Eleazer 2007 - 40 pts w/ Sym. Irreversible Pulpitis, IAN B, Success: 600 mg Ibu/1000 mg Aceto 76%, 1000 mg Aceto 71%, Placebo 46%. NSD but trend towards more success with pre-op analgesic

NO (all LOE 1 studies)

  1. Simpson/Reader 2011 – Combination of 1000 mg Acetominophen/ 800 mg Ibuprofen did NOT significantly improve success of IAN b in Symptomatic irreversible pulpitis cases; Preop Ibu + Aceto did not Inc. success of IAN

  2. Aggarwal 2010 – Sym. Irreversible Pulpitis, IAN B Success: 300 mg Ibu 27%, 10 mg Ketorolac 39%, Placebo 29% - NSD; Preop (1 hr) Ibu or Ketorolac did NOT Inc. success of IAN B (pain during procedure)

  3. Oleson/Reader 2010 – Sym. Irreversible Pulpitis, IAN B Success: 800 mg Ibuprofen 41%, Placebo 35% - NSD; Preop Ibu did not Inc. success of IAN

Contraindications to ASA/NSAIDs

  1. Pregnancy (3rd Trimester only)

  2. Asthmatics – blocks PGE2   Leukotrienes  bronchoconstriction

  3. Sickle Cell Anemia – vasoclusive crisis (acidosis)

  4. Peptic Ulcer Disease – gi protection (blocking cox1), bleeding risk

  5. Crohn’s Disease, Ulcerative Colitis – gi protection (blocking cox1), bleeding

  6. Long-term Steroid use (gut mucosa – potential ulceration)

  7. Uncontrolled Hyperthyroidism

  8. Congestive Heart Failure

  9. Liver Disease – bleeding risk/metabolism of drugs reduced

  10. Chronic Kidney Disease/End Stage Renal Disease (GFR < 15 mL/min)

  11. Previous MI (Olson) – NSAIDs only, Naproxen ok if limted to 7 days

  12. Previous Stroke – Avoid NSAIDs only

  13. Bleeding Disorders – Thrombocytopenia, Hemophilia, von Willebrand’s

  14. Meds: Anti-platelet (Aspirin, Plavix), Anti-coagulants (Coumadin, Heparin), Valproic acid (Epilepsy), Lithium (bipolar), Sulfonylureas (diabetes), Methotrexate (cancer/AI)

*Limit NSAIDs (< 2 wks) with Anti-HTN meds (Beta blockers, ACEI, Diuretics)

Marshall 2002 / Endodontic Topics
Effect of glucocorticoids on Acute inflammation:

  • Blocks release of membrane phospholipids (ie: Arachadonic Acid)

  • Inhibit acute abscess metabolites by inhibition of phosopholipase A2

  • Decrease transcription of cytokines IL-1,2,3,4,5,6,11,12,TNFα.

  • Decrease iNOS

  • Decrease COX2 transcription by monocytes /macrophages

  • Decrease neurogenic inflammation by inhibiting tachykinins

  • Decrease bradykinin due to increase ACE synthesis

Widespread effects on many organ systems are typically seen only at supraphysiological doses given over a long-term period, usually more than 2 wks.

Marshall 2002 / Endodontic Topics

  1. Intraoral IM injection or an intraosseous injection is preferable over and extraoral IM injection. Intraoral injection of steroid is preferable as no assumption about patient compliance is required. A dose of 6-8mg of dexamethasone or 40mg of methylprednisone appears from the literature to be appropriate.

  1. If an oral route is chosen 48mg methyprednisolone/day for 3 days and by extrapolation 10-12mg dexamethasone/day for 3 days should provide significant post treatment pain relief

Intracanal Steroids

  1. Chance/Lin 1987 – Compared Intracanal corticosteroid (2.5% Meticortelone) vs. Saline for intracanal medicament. At 24 hrs, Vital cases: Cortcosteroid sig. reduced post op pain, Necrotic cases: NSD

  1. Moskow/Morse/Krasner 1984 – Corticosteroids (dexamethasone) vs. Placebo. At 24 hrs: Corticosteroid sig. reduced post-op pain compared to placebo. Only Vital teeth were used for the study.

  1. Pierce/Lindskog 1987 – Ledermix (tetracycline/corticosteroid mix) is recommended as an intracanal medication to inhibit external inflammatory root resorption in traumatized teeth.

What is Ledermix? Corticosteroid antibiotic paste:

  1. Triamcinolone Acetonide (1%) - Corticosteroid

  2. Demeclocycline (3%) - Antibiotic

  3. Water soluble cream: Triethanolamine, Calcium Chloride, Zinc Oxide, Sodium Sulphite Anhydrous, Polyethylene glycol

  1. Ehrmann – LOE 1, 223 pts, significantly less post-treatment pain in patients after intracanal administration of Ledermix compared with either CaOH2 or no intracanal dressing (opposes Torabinejad, Walton)

  1. Bryson/Trope 2002Dog study, premolars hemi-sected and extracted, 60 min dry time, replanted following instrumentation + 1) CaOH2 or 2) Ledermix. 4 month histological eval. More favorable healing and less replacement resorption with Ledermix. Possible anti-resorptive effects of tetracycline derivative + anti-inflammatory effects of steroid.

Systemic Steroids:

  1. Marshall/Walton 1984IM Dexamethasone (4 mg) reduced severity of pain at 4hrs & 24 hrs compared to placebo.  Pre-op pain =  Post-op pain.

  1. Krasner/Jackson 1986Oral Dexamethasone (0.75 mg) significantly reduced post-NSRCT pain at 8 & 24 hrs compared to placebo

  1. Glassman/Krasner 1989Oral Dexamethasone (12 mg q4h) significantly reduced post-NSRCT pain at 8 hrs but no difference at 24 & 48 hrs

Injection Techniques for Steroids

  1. Gallatin/Reader 2000 – Single dose of Intraosseous steroid – methylprednisolone (Depo-Medrol 40 mg) sig. reduced pain, percussion pain, and number of analgesics vs. placebo in patient with Symptomatic Irreversible Pulpitis. Depo-Medrol can be used to temporarily alleveliate symptoms of irreversible pulpitis until definitive tx.

  2. Isset/Reader 2003 – Compared Intraosseous DepoMedrol vs. Placebo for reduction of PGE2 and IL-8 in pts with Sym. Irreversible Pulpitis. At day 1, Intraosseous DepoMedrol significantly reduced pulpal levels of PGE2.


  1. Kaufman 1994Intraligamentary injection of methylprednisolone (Depo-Medrol) reduced the frequency and intensity of post-operative pain in comparison to placebo and Mepivicaine plain

Anxiolytic therapy - Benzodiazepines

  1. Hargraves & Dionne 1993 OOOOTriazolam (Halcion) 0.25mg appears to be safe, effective alternative to parenternal sedation with a benzodiazepine for dental outpatients.

  1. Hutter & Dionne 1997 JOE – Oral Triazolam (Halcion) 0.25 mg is safe and more effective anxiolytic agent than diazepam (5.0 mg) for endodontic patients.

  1. Dionne OOO 1997Sublingual Triazolam results in greater anxiolytic activity and less pain perception than oral administration as a result of greater plasma drug levels and may be useful as an alternative for nonprenternal outpatient sedation.

Anxiolytic therapy – Nitrous Oxide

  1. Stanley/Reader – N2O significantly improved success of local anesthesia in Symptomatic Irreversible patients: w/N2O: 50%, w/o N2O: 28% (Sig. Difference)

Post op pain control (pending NSAID contraindications)

  • Pre-op Ibuprofen 600 mg (Menke/Jackson)

  • Post-op Ibuprofen 600 mg + 1000 mg Tylenol (Menhinick/Gutman)

  • Flexible Management pain strategy (Hargreaves)

  • Post-op Occlusal reduction: Vital, no AP, Perc +, Preop pain (Rosenberg)

  • Post-op Steroids: Dexamethasone or Methylprednisolone (Krasner)

NOT Antibiotics, NOT Benedryl

Should antihistamines be prescribed to reduce pain ?
Nevins 1994 JOE – Prophylactic use of Benedryl plays little or no role in abating post-operative pain after instrumentation of necrotic teeth.

Benedryl (Diphenhydramine): 1st generation Anti-Histamine with Anti-cholinergic (parasympathetic acetylcholine), Anti-emetic, and Sedative properties


Mechanisms of Action
L.A. alters the resting potential and  excitation (A.P.) threshold of the nerve by binding to sodium channels and preventing sodium influx
pKa of anesthetic determines amount of acid and base forms of anesthetic present:

pKa =  Base form present extraneuronally = Faster Onset of L.A.

Base form of anesthetic crosses neuronal membrane and converts to acid form

Acid form (NH+) of anesthetic binds to sodium channels to prevent AP transmission
The effect of properties of anesthetic on anesthesia efficacy

Duration: Protein binding affinity, Vasoconstrictor (decreases blood flow/absorption)

Onset: pKa (see above)

Potency/Efficacy: Lipid Solubility (membrane penetration), Tissue pH ( pH =  acid form =  efficacy)
Determining Successful Anesthesia

  1. Dreven/Reader 1987 – EPT as an indictor of pulpal anesthesia. Symptomatic IP patients with 80/80 may still be symptomatic on access.

  1. Certosimo/Archer 1996 – EPT as an indicator of pulpal anesthesia in normal pulps. Less than 80/80, patients symptomatic during treatment.

  1. Cohen/Cha/Spangberg 1993 - Lip anesthesia not reliable indicator of pulpal anesthesia. (Aβ fibers NOT Aδ). DDM (Endo Ice) reliable method of testing for pulpal anesthesia in Irreversible Pulpitis patients – 92% effective

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