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JOURNAL OF ENDODONTICS
Copyright 9 1983 bythe American Associ~ion of Endodontis~
Incidence of Pain Associated with Clinical Factors
During and After Root Canal Therapy. Part 1.
Interappointment Pain
John W. Harrison, DMD, MS, J. Craig Baumgartner, DDS, MS, and Timothy A. Svec, DDS, MS
Patients who begin endodontic therapy with no
symptoms may experience pain during therapy or
after obturation of the canal system. A clinical study
was conducted to determine whether any clinical
factors or conditions are associated with an in-
creased incidence or degree of interappointment or
postobturation pain. Of 229 patients evaluated in
part 1 of this study, 28.8% had slight interappoint-
ment pain and 15.7% had moderate to severe pain.
Statistical analysis showed no significant relation-
ship between interappointment pain and any of the
analyzed clinical factors or conditions.
From historical to modern times, endodontic therapy
has been dedicated to reducing, eliminating, or avoid-
ing pain. Endodontic practitioners avoid overinstru-
mentation, overmedication, and overfilling because it
is believed that pain may result from these practices.
Chemical agents used as irrigants and as intracanal
medicaments are selected or rejected for clinical use
on the basis of their potential for toxicity to periapical
tissues which may result in pain. Obturating materials
are selected on the basis of tissue tolerance in order
to decrease the potential for causing pain and failure
of root canal treatment.
Pain influences clinical practice by prolonging treat-
ment, delaying obturation, and requiring unscheduled
office visits, during and after office hours, for emer-
gency therapy. Single-visit endodontic therapy would
be more widely practiced if it were not for the concern
that postobturation pain may develop. The fear of pain
during or after root canal therapy is of extreme impor-
tance to many patients, leading some to prefer extrac-
tion over endodontic therapy.
Pain is often the entity that signals the necessity for
endodontic treatment and, likewise, it is the entity that
may ultimately signal the failure of endodontic treat-
ment.
The purpose of this study was to determine whether
any clinical factors or conditions are associated with
an increased incidence or degree of pain occurring
384
Printed in U.S.A.
VOL. 9, NO. 9, SEPTEMBER 1983
during or after endodontic treatment in patients who
begin treatment with no symptoms.
The objectives were: to record clinical data relating
to factors and conditions existing before, during, and
at the completion of treatment; to determine the inci-
dence and degree of interappointment and postobtur-
ation pain associated with endodontic treatment; and
to determine through statistical analyses if a signifi-
cant relationship exists between the recorded clinical
factors or conditions and the incidence or degree of
interappointment or postobturation pain.
MATERIALS AND METHODS
The sample was composed of all patients referred
for endodontic therapy who had involved teeth that
were free of symptoms and canal systems closed to
the oral environment. Patients who had received en-
dodontic emergency therapy because of pain were
accepted for the study if the involved teeth were
asymptomatic before the first treatment appointment
and if the root canal systems had been sealed from
the oral environment at the completion of emergency
therapy. Before treatment, patients were randomly
placed into two groups, according to the chemical
agents to be used for irrigation and intracanal medi-
cation.
Teeth of patients in group 1 were irrigated during
canal preparation with 3% hydrogen peroxide solution
(H202) followed by 5.25% sodium hypochlorite solu-
tion (NaOCI), and had a cotton pledget moistened with
formocresol sealed in the pulp chamber between ap-
pointments with a temporary filling material.
Teeth of patients in group 2 were irrigated with
normal saline solution (0.9% sodium chloride solution)
during canal preparation. No intracanal medication
was used between appointments. A dry sterile cotton
pledget was sealed in the chamber with a temporary
filling material.
Endodontic therapy was performed by two endo-
dontists in separate practices who used a common
aseptic clinical technique (1). Each endodontist
treated an approximately equal number of patients.
Vol. 9, No. 9, September 1983 Pain During and After Therapy 385

Rubber dams were used for protection, and instru-
mentation was confined to the canal system and com-
pleted at the first appointment. In group 1 patients,
approximately 1 ml of H202, followed by an approxi-
mately equal amount of NaOCI, was used between
each instrument size during chemomechanical prep-
aration of the canal systems. In group 2 patients, 2 ml
of normal saline solution was similarly used for irriga-
tion. After a final irrigation, the canal systems were
dried with sterile absorbent points.
Patients returned for their second appointment
within 2 to 10 days and were asked by the treating
clinician if they had experienced any discomfort since
the preceding appointment. Interappointment pain
was recorded as none, slight, or moderate to severe,
based on the following criteria. Slight pain was defined
as any discomfort, no matter how brief in duration,
that did not require medication or other palliative
treatment and did not delay obturation at the second
appointment. If any symptoms were present at the
second appointment, obturation was delayed to a later
appointment. Moderate to severe pain was defined as
pain requiring medication or other palliative treatment,
or a delay in obturation of the canal system beyond
the second appointment.
For each tooth, recorded data included the following
clinical factors or conditions: arch location, number of
TABLE 1. Incidence and degree of interappointment pain
associated with group 1 and group 2 patients*
Symptoms G r o u p 1 1 Group25
None 61
Slight 31
Moderate to severe 16
Total cases 108
9 I n c i d e n c e of pain: df = 1, X 2 = 0 . 0 8 5 , p > 0 . 7 0 ; d e g r e e of pain: df = 2, X 2 =
0.151, p > 0.90.
1" Irrigated with 3 % H202 a n d 5 . 2 5 % NaOCI, formocresol used as i n t r a c a n a l m e d i c a -
tion.
~t Irrigated w i t h normal saline solution, no i n t r a c a n a l medication u s e d .
roots, previous emergency treatment, presence or
absence of a periapical radiolucent area, and the
pulpal vitality status. Pulpal vitality was based on
direct clinical observations and not the results of elec-
trical or thermal pulp testing. If bleeding was observed
from tissue within the pulp chamber or root canal, the
pulp was considered to be vital. If no bleeding was
observed, the pulp was considered to be nonvital. Any
tooth that had not been previously opened for pain
was classified as an intact tooth.
The results were statistically analyzed using chi-
square tests to determine whether a significant rela-
tionship existed between any clinical factors or con-
ditions and interappointment pain incidence (i.e. no
pain versus pain) or degree (no pain versus slight pain
versus moderate to severe pain). The criteria used in
the statistical analyses were the same as previously
reported (2, 3). A probability level of 0.05 or less was
considered to be significant.
RESULTS
A total of 236 cases was evaluated in this study.
Seven patients were subsequently dropped from the
study because they could not be followed in part 2 of
the study. Separate analyses using available data on
these seven patients showed that their deletion did
not affect the significance level of any statistical anal-
ysis.
Patients ranged in age from 18 to 82 years of age,
with a mean age of 40.5 years. One hundred and two
TotalCases
were females and 1 27 were males.
66 127 The endodontically involved teeth included 60
35 66
20 36 (26.2%) maxillary anteriors, 39 (1 7%) maxillary pre-
121 229 molars, 35 (15.3%) maxillary molars, 1 1 (4.8%) man-
dibular anteriors, 26 (1 1.4%) mandibular premolars,
and 58 (25.3%) mandibular molars.
Of the 229 patients included in the study, 127
(55.5%) experienced no interappointment pain, 66

TABLE 2. Results of chi-square analyses of interappointment pain between patient groups by clinical category

Teeth Teeth
with no with Teeth
Vital Nonvital Periapi- Periapi- Previ- Intact Single- Multirooted Posterior
cal cal ously rooted Anterior Teeth
teeth teeth Teeth Teeth Teeth
Radiolu- Radiolu- Opened Teeth
cent cent for Pain
Areas Areas
No. of group 1 pa- 23 85 47 61 75 33 55 53 30 78
tients
No. of group 2 pa- 41 80 64 57 70 51 74 47 41 80
tients
Incidence of pain*
X~ 1.85 0.63 0.29 0.07 0.22 1.27 O.10 0.03 2.26 0.37
p >0.10 >0.30 >0.50 >0.70 >0.50 >0.20 >0.70 >0.80 >0.10 >0.50
Degree of pain*
X2 1.23 0.66 0.29 0.18 0.76 0.84 3.29 5.60 4.84 2.71
p >0.50 >0.70 >0.80 >0.90 >0.50 >0.50 >0.10 <0.10 > 0.05 <10 > 0.05 >0.20
* For i n c i d e n c e of pain: df = 1 ; for d e g r e e of pain: df = 2.
 386 Harrison et al. Journal of Endodontics

( 2 8 . 8 % ) had slight pain, and 3 6 ( 1 5 . 7 % ) had moderate TABLE 5. Interappointment pain associated with teeth
to severe pain (Table 1). previously opened for pain and intact teeth*

T h e r e was no significant d i f f e r e n c e in interappoint- Teeth Pre-

ment pain i n c i d e n c e or degree b e t w e e n patient g r o u p s viously Total
Symptoms Opened Intact Teeth Cases
(Table 1). Further analysis s h o w e d no significant dif-
for Pain
ference in interappointment pain b e t w e e n g r o u p I and
g r o u p 2 patients in vital teeth, nonvital teeth, teeth None 80 47 127
Slight 40 26 66
with no periapical r a d i o l u c e n t areas, teeth with peri- Moderate to severe 25 11 36
apical r a d i o l u c e n t areas, teeth p r e v i o u s l y opened for Total cases 145 84 229
pain, intact teeth, single-rooted teeth, multirooted * I n c i d e n c e of pain: d f = 1, x 2 = 0 . 0 1 1 , p > 0 . 9 0 d e g r e e ; of p a i n : d f = 2, X 2 =
teeth, anterior teeth, posterior teeth, maxillary teeth, 0.796, p > 0.50.

or m a n d i b u l a r teeth (Table 2).

In vital teeth, there was a much h i g h e r i n c i d e n c e TABLE 6. Interappointment pain associated with single-rooted
and d e g r e e of i n t e r a p p o i n t m e n t pain in g r o u p 2 pa- and mulUrooted teeth*

tients ( 6 1 % i n c i d e n c e of pain, with 1 9 . 5 % having Single- Multirooted Total

moderate to severe pain) as c o m p a r e d with g r o u p 1 Symptoms rooted
Teeth Cases
patients ( 4 3 . 5 % incidence of pain, with 8 . 7 % having Teeth
moderate to severe pain). However, these differences None 74 54 127
were not significant. Slight 39 27 66
Moderate to severe 17 19 36
No s i g n i f i c a n t differences in i n t e r a p p o i n t m e n t pain Total cases 129 1O0 229
was f o u n d between vital and nonvital teeth (Table 3),
* I n c i d e n c e of pain: d f = 1, X 2 = 0 . 1 6 2 , p > 0 . 5 0 ; d e g r e e of pain: d f = 2, X ~ = 1 50,
teeth w i t h o u t periapical r a d i o l u c e n t areas and teeth p > 0.30.

with periapical r a d i o l u c e n t areas (Table 4), teeth pre-

v i o u s l y o p e n e d for pain and intact teeth (Table 5), TABLE 7. Interappointment pain associated with anterior and
single-rooted teeth and multirooted teeth (Table 6), posterior teeth*
anterior teeth and posterior teeth (Table 7), or maxil- Anterior Posterior Total
lary teeth and mandibular teeth (Table 8). Analysis by Symptoms Teeth Teeth Cases
tooth g r o u p s s h o w e d no s i g n i f i c a n t differences in None 40 87 127
i n t e r a p p o i n t m e n t pain among m a x i l l a r y or m a n d i b u l a r Slight 18 48 66
anteriors, premolars, and molars. Moderate to severe 13 23 36
The results reported by each clinician were sepa- Total cases 71 158 229
rately a n a l y z e d and the individual results paralleled * I n c i d e n c e of pain: d f = 1, X 2 = 0 . 0 2 9 , p > 0 . 8 0 ; d e g r e e of pain: df = 2, X ~ =
0.875, p > 0.50.
the c o m b i n e d results in all c a t e g o r i e s of analysis.
TABLE 8. Interappointment pain associated with maxillary and
TABLE 3. Interappointment pain associated with vital and mandibular teeth*
nonvital teeth*
Maxillary Mandibular Total
Vital Nonvital Total Symptoms
Teeth Teeth Cases
Symptoms Teeth Teeth Cases
None 70 57 127
None 29 98 127
Slight 41 25 66
Slight 25 41 66 Moderate to severe 23 13 36
Moderate to severe 10 26 36 Total cases 134 95 229
Total cases 64 165 229
* i n c i d e n c e of pain: d f = 1, X 2 = 1 . 3 5 , p > 0 . 2 0 ; d e g r e e of pain: d f = 2, X 2 = 1 . 3 7 ,
* I n c i d e n c e of pain: d f = 1, X 2 = 3 . 7 1 , p < 0 . 1 0 > 0 . 0 5 ; d e g r e e of pain: d f = 2, X 2 p > 0.50.
= 4.94, p< 0.10 >0.05.

TABLE 4. Interappointment pain associated with teeth with no DISCUSSION

periapical radiolucent areas and teeth with periapical
radiolucent areas* The results of part 1 of this s t u d y s h o w that none of
Teeth with the analyzed clinical factors or c o n d i t i o n s have a
Teeth with significant relationship to i n t e r a p p o i n t m e n t pain in pa-
No Peri-
Symptoms apical Periapical Total
Radiolucent Cases tients w h o begin e n d o d o n t i c t h e r a p y w i t h o u t symp-
Radiolu- toms.
Areas
cent Areas
Some chemical a g e n t s that have been used in en-
None 58 69 127 d o d o n t i c t h e r a p y as irrigants or as intracanal medi-
Slight 35 31 66
Moderate to severe 18 18 36 caments have been indicted because of their potential
Total cases 111 118 229 for toxicity. Based on the results of l a b o r a t o r y studies
* i n c i d e n c e of pain: d f = 1, X 2 = 0 . 9 2 , p > 0 . 3 0 ; d e g r e e of pain: d f = 2, X 2 = 0 . 9 9 ,
( 4 - 7 ) , some investigators have c o n c l u d e d that the
p > 0.50. clinical use of these chemical agents may result in
Vol. 9, No. 9, S e p t e m b e r 1983
periapical irritation and pain. Endodontic texts ( 1 , 8 -
10) contain warnings that the use of 5.25% NaOCI
(alone or in combination with 3% H202) as an irrigant
and the use of formocresol as an intracanal medication
may cause pain by irritating the periapical tissues. In
an effort to avoid endodontic "flare-ups," some prac-
titioners have chosen not to use an intracanal medi-
cament between appointments and to use normal
saline solution as an irrigant during instrumentation of
the canal system.
In this study, the use of 3% H202 and 5.25% NaOCI
as irrigants, combined with the use of formocresol as
an intracanal medicament, was not associated with an
increased incidence or degree of interappointment
pain. This finding supports the findings of previous
studies (2, 3, 11 ).
Part 2 of this study analyzes pain incidence and
degree after obturation of the canal systems in the
same sample of patients.
S U M M A R Y AND C O N C L U S I O N S
The incidence and degree of interappointment pain
occurring in patients who began endodontic treatment
with no symptoms were recorded. Statistical analyses
were used to determine whether a significant relation-
ship existed between interappointment pain and any
recorded clinical factors or conditions. The following
conclusions were drawn:
No significant relationship between interappoint-
ment pain and any of the analyzed clinical factors or
conditions could be determined.
Pain During and After Therapy 387
In patients beginning endodontic treatment with no
symptoms, the occurrence of interappointment pain is
not clinically predictable.
The clinical use of 3% H202, 5.25% NaOCI, and
formocresol is not associated with an increased inci-
dence or degree of interappointment pain.
Dr. Harrison is a professor, department of endodontics, and director,
endodontic graduate program at Baylor College of Dentistry. Dr. Baumgartner
is assistant chief, endodontics, US Army Institute of Dental Research, Walter
Reed Army Medical Center, Washington, DC. Dr. Svec is chief, endodontics,
US Army Dental Activity, Fort Sam Houston, TX. Address requests for reprints
to Dr. John W. Harrison, Baylor College of Dentistry, 3302 Gaaton Avenue,
Dallas, TX 75246.
References
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Febiger, 1976:195-202, 580-2.
2. Harrison JW, Svec TA, Baumgartner JC. Analysis of clinical toxicity of
endodontic irrigants. J Endodon 1977;4:6-11.
3. Harrison JW, Bellizzi R, Osetek EM. The clinical toxicity of endodontic
medicaments. J Endodon 1979;5:42-7.
4. Torneck CD. Reaction of hamster tissue to drugs used in sterilization
of the root canal. Oral Surg 1961 ;14:730-47.
5. Powell DL, Marshall FJ, Melfi RC. A histopathologic evaluation of tissue
reactions to the minimum effective doses of some endodontic drugs. Oral
Surg 1973;36:261-72.
6. Schilder H, Amsterdam M. Inflammatory potential of root canal medi-
caments. Oral Surg 1959;1 2:211-21.
7. Spangberg L. Cellular reaction to intracanal medicaments. In: Gross-
man LI, ed. Transactions Fifth International Conference of Endodontics.
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1982:320, 325.
10. Morse DR. Clinical endodontology. Springfield, IL: Charles C Thomas,
1974:326, 458.
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medicaments. J Endodon 1981 ;7:272-6.