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What Is The Effect of No Endodontic Debridement On Postoperative Pain For Symptomatic Teeth With Pulpal Necrosis?
What Is The Effect of No Endodontic Debridement On Postoperative Pain For Symptomatic Teeth With Pulpal Necrosis?
Key Words
Endodontic debridement, endodontic pain, pulpal
necrosis, symptomatic endodontic patients
Clinical Research
Materials and Methods
One hundred eight adult patients presenting for emergency treatment initially participated in this study. All subjects were in good physical condition as determined by a written questionnaire and oral
questioning. Each patient was required to be 18 years or older and
be in good health with an American Society of Anesthesiologists classification of I or II. Patients were excluded from the study if they were taking chronic pain medications; if they were allergic to local anesthetics,
ibuprofen, acetaminophen, or codeine; if they reported a history of
gastrointestinal problems, angioedema, or bronchospastic activity to
aspirin or other nonsteroidal anti-inflammatory drugs; or if they were
unable to give informed consent. In addition, prisoners and mentally
disabled patients were excluded. All female subjects were questioned
regarding pregnancy or suspected pregnancy. None were allowed to
participate if they were pregnant, suspected of being pregnant, or
were trying to conceive. Approval for this study was obtained from
the universitys human subjects review committee, and written consent
was obtained from each participant.
Each patient had a distinct radiolucency at the apex of a symptomatic tooth and a diagnosis of pulpal necrosis as shown by a negative
response to an electric pulp tester (Analytic Technology Corp, Redmond, WA) and Endo-Ice (Hygenic Corp, Akron, OH). Patients were
also required to have no or mild swelling and no draining sinus tract.
The patients temperature was taken orally using the SureTemp digital
thermometer (Welch Allyn Ltd, Navan, CO), and any patient with a temperature above 100 F was excluded from participation.
Each patient rated his or her initial pain on a Heft-Parker visual
analog scale (VAS) (13). The VAS was divided into 4 categories as
described previously (5). To qualify for the study, patients had to present with moderate to severe pain. Each patient also completed the
Corah Dental Anxiety Scale questionnaire (14).
Before the experiment, the 2 regimens (debridement or no
debridement) were randomly assigned 5-digit numbers from a random
number table. The number assignment determined whether debridement or no debridement was performed for each patient. Only the
random numbers were recorded on the data collection sheet to maintain blinding of the experiment.
Each patient was anesthetized with 2 cartridges of 2% lidocaine
with 1:100,000 epinephrine (Xylocaine; AstraZeneca LP, Dentsply,
York, PA) administered by an inferior alveolar nerve block or maxillary
infiltration. Patients in the debridement group had the affected tooth
isolated with a rubber dam and endodontic debridement performed using 3% sodium hypochlorite irrigation and hand and rotary files. The
canals were prepared to a minimum size of a 30/.04 or 40/.04 depending on the tooth and canal treated. The canals were dried with paper
points, and calcium hydroxide (Multi-Cal; Pulpdent Corp, Watertown,
MA) was placed as an intracanal medicament. The teeth were temporized with Cavit (Cavit G; 3M ESPE, Seefeld, Germany), and the patients
were scheduled for root canal completion. The senior author (R.S.)
performed all endodontic treatment.
For the no debridement group, local anesthesia was administered
using 2 cartridges of 2% lidocaine with 1:100,000 epinephrine as
described previously. This completed the treatment phase.
If patients presented to the clinic already taking an antibiotic, they
were instructed to finish their current regimen if the antibiotic and
dosage were clinically appropriate. Patients who were not on antibiotics
or were not prescribed an appropriate antibiotic regimen received a
prescription for an antibiotic (500 mg penicillin; if allergic, 300 mg
clindamycin) to be taken every 6 hours until gone. Antibiotics were
administered because a number of presenting patients were already
on antibiotics, and we wanted to eliminate this variable from the study.
Sebastian et al.
Debridement
No
debridement
36 12
20 female,
26 male
119 27
9
39 17
25 female,
24 male
120 27
9
7% (3/46)
26% (12/46)
67% (31/46)
12% (6/49)
16% (8/49)
71% (35/49)
52% (24/46)
48% (22/46)
51% (25/49)
49% (24/49)
Age (y)
Sex
Presenting pain
Corah anxiety
(median)
Tooth location
Anterior
Premolar
Molar
Jaw
Maxilla
Mandible
P value*
.3666
.4616
.9088
.3952
.3914
.9105
Num
DF
Den
DF
Chi-square
Pr >
Chi-square
Group
Day
Group by day
Sex
Group by sex
Sex by day
Group by sex by day
1
5
5
1
1
5
5
546
546
546
546
546
546
546
5.09
32.93
4.64
10.57
1.27
3.74
5.72
.0241
<.0001
.4608
.0011
.2593
.5879
.334
Group (debridement vs no
debridement)
Sex (female vs male)
95%
confidence
limits
Estimate
DF
1.519
546
1.055
2.185
0.548
546
0.38
0.788
Clinical Research
TABLE 3. Percentages and Discomfort Ratings of Postoperative Pain for the Debridement and No Debridement Groups (excluding patients who took narcotics)
Group
Day 0*
Debridement
No debridement
Day 1
Debridement
No debridement
Day 2
Debridement
No debridement
Day 3
Debridement
No debridement
Day 4
Debridement
No debridement
Day 5
Debridement
No debridement
None
Mild
Moderate
Severe
Median
P value
3% (1/37)
9% (4/42)
35% (13/37)
38% (16/42)
54% (20/37)
38% (16/42)
8% (3/37)
14% (6/42)
58.0
57.5
.8587
8% (3/36)
7% (3/43)
42% (15/36)
26% (11/43)
47% (17/36)
60% (26/43)
3% (1/36)
7% (3/43)
52.0
59.0
.0982
4% (2/45)
8% (4/47)
49% (22/45)
32% (15/47)
42% (19/45)
49% (23/47)
4% (2/45)
11% (5/47)
36.0
58.0
.0975
27% (12/44)
15% (7/47)
39% (17/44)
40% (19/47)
32% (14/44)
38% (18/47)
2% (1/44)
6% (3/47)
22.0
46.0
.0496
23% (10/44)
15% (7/47)
50% (22/44)
36% (17/47)
27% (12/44)
42% (20/47)
0% (0/44)
6% (3/47)
20.5
45.5
.0170
39% (17/44)
19% (8/43)
39% (17/44)
44% (19/43)
23% (10/44)
30% (13/43)
0% (0/44)
7% (3/43)
3.0
38.0
.0060
availability. The patient was instructed to stop taking the ibuprofen and
acetaminophen once starting the escape medication to avoid exceeding
recommended drug dosing. The patient was seen emergently in the
clinic if the need arose.
Patients received a diary for the day of the appointment and 5 days
postoperatively to record any pain they were having and the amount of
pain (ibuprofen/acetaminophen combination or escape) medication
taken. Patients recorded the type and number of pain medications taken
during the time period between the completion of the endodontic procedure and before going to bed the night of the appointment after the
local anesthesia had worn off. For the next 5 days, patients recorded
pain on the Heft-Parker VAS and the type and number of pain medications taken each day. Patients were asked to return all unused medications upon completion of the study to verify diary input. The patients
assigned to the no debridement group were scheduled for endodontic
treatment 5 days later or at their earliest convenience. Success
was defined as none or mild postoperative pain and no use of narcotic
medications. Overall success was calculated for the debridement and no
debridement groups.
The data from this study were statistically analyzed. Comparisons
between the debridement and no debridement groups for age and initial
pain ratings were made using the randomization test. Comparisons in
sex and jaw were analyzed via chi-square tests. Differences in tooth
type were analyzed using the Fisher exact test. Corah anxiety ratings
were assessed using the Mann-Whitney-Wilcoxon test.
Between-group differences in success were evaluated using a
repeated measures logistic regression with group, day, and sex as the
independent variables. A mixed model analysis of variance with postoperative day, patient sex, and treatment group as the independent variables was used to evaluate total analgesic use. Tooth type and jaw
were included as random variables. Post hoc testing was performed using the Tukey-Kramer procedure. Because the postoperative pain values
were not normally distributed, they were analyzed nonparametrically
using multiple randomization tests with the P values adjusted using
the step-down Bonferroni method of Holm. Comparisons were considered significant at P < .05. For VAS pain scores, assuming a standard
deviation of 50.3 (5), a difference of 30 mm could be detected
with a power of 0.80 with 45 patients per group.
Results
A total of 108 subjects were enrolled in this study. Thirteen subjects were disqualified for the following reasons: 1 because of a fracture
detected upon endodontic access, 11 for not returning postoperative
surveys, and 1 for not disclosing the use of Percocet daily for chronic
back pain. Ultimately, 10 patients were disqualified from the debridement group, and 3 patients were disqualified from the no debridement
group. Therefore, the total number of subjects analyzed was 46 in the
debridement group and 49 in the no debridement group.
TABLE 4. Mean Number of the Combination Medications Taken (excludes
patients who took narcotics)
Group
Day 0*
Debridement
Nondebridement
Day 1
Debridement
Nondebridement
Day 2
Debridement
Nondebridement
Day 3
Debridement
Nondebridement
Day 4
Debridement
Nondebridement
Day 5
Debridement
Nondebridement
Number of
patients
Mean number
tablets
37
43
4.8 2.7
4.4 3.1
1.0000
37
43
6.3 3.8
7.8 3.9
.7874
37
43
4.9 3.8
6.8 4.0
.4742
37
43
3.6 3.6
5.9 4.1
.1996
37
43
2.9 4.0
4.6 3.6
.6703
37
40
2.2 3.9
4.2 3.7
.4562
P value
Clinical Research
Table 1 shows the preoperative variables. There were no statistically significant differences between the 2 groups with regard to age,
sex, presenting pain, Corah anxiety ratings, tooth location, or jaw.
Table 2 shows the regression summary for treatment success.
There were significant effects for treatment group (odds ratio =
1.519; 95% confidence interval, 1.0552.185 for debridement vs no
debridement), sex (odds ratio = 0.548; 95% confidence interval,
0.3800.788 for females vs males), and day. All interaction effects
were not significant (P > .259).
Table 3 shows pain by day for the debridement and no debridement groups. Moderate to severe pain was experienced by 52%62%
of the patients the night of the treatment and 50%67% of the patients
on day 1, with the pain ratings decreasing over the next 4 days. Significantly lower pain values were noted for the debridement group for days
3 through 5. Figure 1 shows the postoperative pain ratings over the 5
days.
Table 4 and Figure 2 show the mean number of combination
ibuprofen/acetaminophen tablets taken by day for the debridement
and no debridement groups. The highest number of medication use
was on day 1, with decreasing use over the next 4 days. Twenty percent
(9/46) of patients in the debridement group and 12% (6 of 49) in the
no debridement group took escape medications with no significant
(P = .3218) difference between the groups (Fig. 3).
Discussion
Differences in the preoperative variables would be minimized
because no statistically significant differences were shown between
groups (Table 1). The presenting initial moderate pain level
(Table 1) is representative of emergency patients with symptomatic
teeth, a pulpal diagnosis of necrosis, and a periapical radiolucency as
shown by Wells et al (5). Because most subjects in both groups reported
low to moderate Corah scores (Table 1), anxiety may not have played a
large role in influencing the pain associated with debridement or no
debridement. The influence of tooth location was minimized because
the teeth were evenly distributed (Table 1).
The debridement group had a significantly higher odds of success
(no to mild pain and no narcotic use) than the no debridement group.
Therefore, the best clinical outcome would be to completely debride the
tooth at the emergency visit. Endodontists would be likely to perform
complete debridement because of their advanced training and experience. However, inexperienced operators may not be able to perform
complete debridement at the emergency visit.
The patients in the no debridement group did not get worse over
the 5 days, indicating that analgesics may help these symptomatic patients presenting with a necrotic pulp and associated periapical radiolucency. The use of antibiotics would not be expected to help because
the use of antibiotics does not result in a significant improvement in the
4
Sebastian et al.
Clinical Research
We concluded patients receiving debridement or no debridement
had a decrease in postoperative pain and medication use over the
5 days. Complete endodontic debridement resulted in a statistically
higher success rate when compared with no endodontic debridement,
but there was no significant difference in the need for escape (narcotic)
medication between the 2 groups.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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