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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 165-170

Pattern of postoperative pain during endodontic treatment – A randomized control study


1 Department of Conservative and Endodontics, SJ M Dental College and Hospital, Chitradurga, Karnataka, India
2 Department of Conservative and Endodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
3 Private Practitioner, Patiala, Punjab, India

Date of Submission14-Aug-2021
Date of Decision18-Aug-2021
Date of Acceptance27-Aug-2021
Date of Web Publication14-Nov-2022

Correspondence Address:
Anupama Kiran
SJ M Dental College and Hospital, Chitradurga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijds.ijds_107_21

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  Abstract 


Background: The purpose of this study was to evaluate the effect of occlusal relief on the pattern of postoperative pain at different time intervals in patients diagnosed with irreversible pulpitis and apical periodontitis. The null hypothesis proposed was, there is no difference in the postoperative pain in the experimental and control groups. Materials and Methods: In this randomized study, sixty posterior teeth with irreversible pulpitis and slight tender to percussion were included. Root canal treatment was initiated and biomechanical preparation was done. Closed dressing was given after placing calcium hydroxide as an intracanal medicament. The patients were randomized using computer-generated randomization software into the experimental group where occlusal contacts were relieved (n = 30) and to the control group where occlusal contacts were left intact (n = 30). Postoperative pain at different intervals was recorded using the Heft-Parker Visual Analog Scale and analyzed. Results: There is no statistically significant difference in the incidence of postoperative pain between the two groups. There is a significant reduction in pain at 6 h within the groups compared to all other time intervals, and flare-ups were reported in the occlusal intact group. Conclusion: The pattern of postoperative pain did show a gradual reduction in the occlusion relieved group. Flare-ups were reported in the occlusion intact group. Within the limitations of the study, the occlusal reduction could play an important role in prevention of flare-ups during endodontic treatment.

Keywords: Endodontic treatment, occlusal surface, pain, pattern of pain, randomized clinical trial


How to cite this article:
Kiran A, Chidanadappa RN, Kaur A. Pattern of postoperative pain during endodontic treatment – A randomized control study. Indian J Dent Sci 2022;14:165-70

How to cite this URL:
Kiran A, Chidanadappa RN, Kaur A. Pattern of postoperative pain during endodontic treatment – A randomized control study. Indian J Dent Sci [serial online] 2022 [cited 2022 Dec 9];14:165-70. Available from: http://www.ijds.in/text.asp?2022/14/4/165/361192




  Introduction Top


Endodontic postoperative pain is one of the major reasons for avoiding the treatment by patients. It is defined as the pain of any degree that occurs after the initiation of root canal treatment. The prevalence of postoperative pain after root canal treatment has been reported to be between 3% and 58% of patients.[1]

The postoperative pain is frequently managed by nonsteroidal anti-inflammatory drugs.[2] Some of the treatment modalities used for the relief of inter- or postoperative pain are use of corticosteroids,[3] long-acting anesthesia,[4] and occlusal relief.[5]

A controversy exists regarding the removal of occlusal contacts for prevention of postoperative pain. Gatewood et al.,[6] Natkin,[7] and Rosenberg et al.[8] have suggested that the removal of occlusal contacts has been beneficial in reducing postoperative pain in certain specific situations. On the contrary, Creech et al.,[9] Jostes,[10] and Parirokh[11] established no positive correlation between postoperative pain and occlusal relief. After the review of literature, it was found that the mere prevalence of pain is not very conclusive and a need to study the improvement and deterioration of pain in both the groups at different time intervals. The present research question is, does the occlusal relief have any effect in reduction of postoperative pain?

Pain is a subjective experience influenced by physical (genetic) and psychological factors.[2] In the clinical scenario, measurement of pain is complex and has been done by either numeric or verbal self-rating scales. The Heft-Parker Scale is a combined metric scale (0–170 mm) with multiple verbal cues aimed for improving communication and correlation between scales designed for pain measurement.[12],[13] It is a categorical four-point scale with no pain, mild pain, moderate pain, and severe pain. This scale has been regarded as a reliable and reproducible measuring tool for clinical pain trials.[2]

The purpose of this randomized controlled study was to evaluate the effect of occlusal relief on incidence and pattern of postoperative pain levels at different time intervals in patients diagnosed with irreversible pulpitis and apical periodontitis without swelling using the Heft-Parker Visual Analog Scale. The null hypothesis proposed was, there is no difference in the postoperative pain in the experimental and control groups.


  Materials and Methods Top


The sample size estimation was based on an error of α = 0.05 (95% confidence limit) at the power of 85% and required sample size of 27 in each group to which a 10% dropout rate was added. The patients who had visited the outpatient department for treatment were recruited. Approval from the institutional ethics panel was obtained.

The inclusion criteria for the study were healthy patients complaining of severe pain to cold stimuli, in carious posterior tooth (molar or premolar) with mild tenderness on percussion and radiographically no periapical changes. The preoperative pain had to be <30 mm on the Heft-Parker Visual Analog Scale (VAS).

The exclusion criteria were the participants younger than 18 years and older than 65 years, patients on medications (E.g. Analgesics, steroids, antidepressants, and antianxiety drugs). Patients who have history of allergy to local anesthetic agents. Tooth greater than Grade 1 mobility and more than 5-mm pocket depth. Pregnancy and lactation, history of significant medical conditions (American Society of Anesthesiologists class II or higher), patients with moderate-to-severe pain, presence of infection and swelling, periapical radiolucency, tooth with no opposing tooth and previously root canal-treated tooth.

A prolonged exaggerated response (moderate-to-severe pain) to the cold stimuli for more than 10 s and mild tenderness to percussion were the criteria for the clinical diagnosis of irreversible pulpitis. Tooth response to electric pulp tester (Parkell Inc., New York) confirms the diagnosis. Radiographic evaluation was done to rule out the periapical lesion. Each patient completed the Heft-Parker VAS before the initiation of treatment. The study design and treatment protocol were explained to all the qualifying patients, and informed consent was obtained.

Sixty healthy adult patients participated in this prospective randomized, single-blind, parallel controlled study. The teeth were anesthetized by 2-ml local anesthesia containing lignocaine 2% with 1:80000 adrenaline (Lignox A 2% Warren, Indoco). After applying the rubber dam, access cavity preparation and working length determination was done which was confirmed with the help of periapical radiographs and apex locator (Root ZX, J. Morita, Tokyo, Japan). A glide path was created and the root canals were prepared by using the crown-down technique keeping the working length 1 mm short of the radiographic apex. K3 rotary file system (SybronEndo, USA) was used for shaping and cleaning. Sodium hypochlorite 3% was used as an irrigant with 17% EDTA (File-Rite semi gel, Kit-Pulpdent, USA), during instrumentation. The root canals were prepared to a minimum of 0.4 taper 25, and a calcium hydroxide dressing was given and sealed with temporary restorative material (Cavit W, 3M, ESPE).

For the purpose of randomization, all the patients were allotted a number. These numbers were randomized into experimental and control groups by using computer-generated randomization software (www.randomiser.org). The method of equal randomization was followed with the allocation ratio of 1:1 for both the groups. For all sixty patients, envelopes were prepared with numbers written on top. The group under which they were allocated by the computer-generated software was written in a paper and sealed by the dental nurse not involved in the study. When the cleaning and shaping were completed, the envelopes were given to the operator. The sealed envelopes were opened by the operator, and the patients were categorized either in the group with occlusal reduction (experimental group) or group without occlusal reduction (control group). For the experimental group, the occlusal contacts (functional cusps) were marked with the articulating paper and were removed using high-speed air-rotor handpiece with diamond bur by reducing about 1 mm. To overcome the bias, similar motion was simulated in the control group, but the occlusal contacts were not removed.

The patients were explained about the Heft-Parker Visual Analog Scale and asked to report after 6 h, 12 h, 18 h, 24 h, 2 days, 3 days, 4 days, 5 days, 6 days, and 7 days. The Visual Analog Scale was divided into four categories: no pain corresponded to 0 mm; 1 mm–54 mm corresponded to “faint, weak, or mild pain;” 55 mm–114 mm corresponded to “moderate” pain; and 114 mm–170 mm corresponded to “strong, intense, and maximum possible.”[14],[15],[16] All patients were instructed to report to emergency in case of severe pain.

The VAS forms were analyzed and tabulated in Microsoft Excel Sheet (Microsoft Office Excel 2003: Microsoft, Seattle, WA) for statistical evaluation using SPSS 15.0 (Chicago, IL, USA). Pain assessment at various time intervals was summarized and mean and standard deviations were noted. Independent t-test was used for the comparison of means between the two groups. Independent samples Mann–Whitney was used for comparisons between the two independent groups which aided in either accepting or rejecting the hypothesis. Repeated measures ANOVA (analysis of variance) was used for pairwise comparison within the group. Cochran Q, an extension of McNemar test, was used to compare if both the treatments had identical effects. Fisher's exact test was used to assess the association between gender and pain status at various time intervals and also to assess the association between pain and the type of tooth (premolar or molar).


  Results Top


Sixty patients with thirty in each group were treated. Total 28 patients in the control group and 29 patients in the experimental group were assessed. One patient in the experimental group and two patients in the control group were excluded from the study as they did not report back with their VAS forms.

Out of 57 patients, 37 (64.91%) were women and 20 (35.08%) were men. Twenty-six teeth (45.61%) treated were maxillary and 31 (54.38%) were mandibular. Out of which, 10 (17.54%) were premolars and 47 (82.45%) were molars. The mean age in the control group was 31.21 ± 8.13 and in the experimental group was 32.86 ± 12.20.

Overall, the pain assessment by comparing the means between the experimental and control groups shows statistically no significant difference (P > 0.05) at different time intervals [Table 1]. At the 6-h [Figure 1] and at 24-h [Figure 2] follow-up, the pain felt by the patients significantly reduced over time and was consistent in both the groups.
Table 1: Deference in pain status between with and without occlusion

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Figure 1: Intensity of pain at 6 h in control and experimental groups

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Figure 2: Intensity of pain at 24 h in control and no experimental groups

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Pearson Chi-square test results showed that the difference in pain status between the experimental and control groups at 6 h is not statistically significant (P > 0.05). The crude odds ratio is 1.17 [Table 2].
Table 2: Deference in pain status between with and without occlusion

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The repeated measures ANOVA test (extension of paired t-test) was performed to study the detailed comparison of pattern of pain. A statistically significant (P < 0.05) reduction of pain was seen in the control group between 6 h and 18 h, 24 h, day 6, and day 7, whereas in the experimental group, a statistically significant reduction of pain was seen between 6 h and all the other time intervals.

The independent samples Mann–Whitney U-test showed a statistically insignificant difference (P > 0.05) in the distribution of pain scores between males and females in both the groups. The crude odds ratio is 2.33. Fisher's exact test results showed that the association between gender and pain status at all intervals was statistically insignificant (P > 0.05).

The difference in the distribution of pain between the molar and premolar teeth was statistically insignificant (P > 0.05) in both the groups. The association between the tooth (premolar/molar) and pain status at all time intervals was also statistically not significant (P > 0.05). The crude odds ratio is 3.17.


  Discussion Top


The role of providing occlusal relief during root canal treatment has been debatable. From the review of literature, it is observed that the pulpal diagnosis and the periradicular diagnosis have played a key role in evaluating the role of occlusal relief during root canal treatment. Natkin E. has advised that the occlusal relief may be beneficial in cases with acute abscess which are painful on biting.[7] Antrim et al. have suggested, regardless of the diagnosis, occlusal reduction will be beneficial.[14] Two surveys by the Diplomats of American Board were conducted, the first survey in 1977 suggested the occlusal adjustment was commonly performed in two conditions, in vital pulp with irreversible pulpitis with no periapical involvement and the other in nonvital teeth with apical periodontitis and no swelling. A decade later, the trend was toward (74%) adjusting the occlusion in cases with apical periodontitis and no swelling.[6],[15],[16] As this popular notion persists, in the present study, we have attempted to evaluate the effect of occlusal relief on pattern of post endodontic pain reduction in cases with irreversible pulpitis and apical periodontitis with no swelling. Selection of cases is based on the criteria of apical periodontitis as it confirms the presence of root canal infection.[17],[18]

During biochemical preparation, the extrusion of the debris into the periapex which can lead to painful inflammatory and immunological reactions.[19],[20] In the present study, the biochemical preparation was done using engine-driven nickel–titanium system instead of stainless steel files, as engine-driven nickel–titanium systems extruded less debris and irrigant, which could reduce the postoperative pain.[21] As well as in the present study, the crown-down technique was used which has been shown to be more superior to step-back technique in debris extrusion.[22]

Sathorn et al.[1] stated that measuring of the mere prevalence of the postoperative pain is inadequate and stressed on the importance of measuring both the improvement and deterioration of the pain. Hence, in the present study, the prevalence as well as pattern of postoperative pain after root canal therapy is evaluated.

In the present study, we have found that the occlusal relief did not have a statistically significant effect on the postoperative pain. The results are in accordance with the study conducted by Creech,[9] Jostes and Holland,[10] and Parirokh.[11] In contrast, the study conducted by Rosenberg et al.[8] did show a positive correlation between the occlusal relief and postoperative pain. The reasons could be the inclusion criteria in their study which involved various clinical profiles such as swelling, stoma, periradicular radiolucency, and presence of preoperative pain.

Overall, the pain assessment by comparing the means between the experimental and control groups shows statistically no significant difference (P > 0.05) at different time intervals. The occurrence of pain during the first 6 h in the experimental group was 75.87% and in the control group 78.58%. At 24 h, the percentage of pain in the experimental group was 34.47% and in the control group 39.28%. At the 6-h interval in the control group, 64.28% reported mild pain in the control group and 48.27% reported mild pain in the experimental group. Crude odds ratio shows that there are 1.17 times more chances of having pain in the control group when compared to the experimental group at 6 h.

At 6 h, 10.34% of the patients in the experimental group reported severe pain and 3.57% reported severe pain in the control group. The initial pain could be due to various factors such as extrusion of debris or irrigants which could result in inflammation of periapex. Although crown-down technique was used during biomechanical preparation to reduce the extrusion of debris, a complete prevention of extrusion might not have resulted. The occurrence of severe pain was reported in both the groups, and a gradual reduction in the pain was reported during the further time intervals.

At 24 h, in the control group, 39.28% had mild pain and no moderate or severe pain was reported. In the experimental group, 27.58% had mild and 6.89% reported moderate pain. A gradual reduction in the pain was recorded in the experimental group, whereas severe pain was reported in the control group at day 2.

The pairwise comparison of pain at 6 h and all other time intervals (12 h, 18 h, 24 h, day 2, day 3, day 4, day 5, day 6, and day 7) in the experimental group showed a statistically significant reduction in pain, whereas in the control group, a statistically significant decrease in pain was not recorded at day 2, day 3, day 4, and day 5.

Another outcome of the present study worth discussing is that although the overall postoperative pain in between the molars and premolars was statistically not significant, the crude odds ratio shows there are 3.17 times more chances of pain occurring in molars when compared to premolars at 6-h interval. The overall postoperative pain between the males and females was also statistically not significant, but the crude odds ratio shows that there are 2.33 times more chances of females having more pain in comparison to males at the first 6 h. Further studies are needed to confirm the clinical relevance of the above data.

A significant finding of the present study, three patients(10.71%) in the control group reported severe pain at day 2 but no flare-ups were recorded in the experimental group at day 2 or later [Table 3]. A similar finding was observed in a study conducted by Parirokh et al.[11] This finding suggests that the reduction of occlusal contacts might play an important role in prevention of flare-ups during root canal treatment.
Table 3: Comparisons of means between control and experimental groups

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The failures to record more definitive profiles and trends in diminishing postoperative pain may be attributed to less number of subjects and different dependent and independent parameters.

The coronal coverage of crowns is considered to be the choice of restoration in root canal-treated teeth and is known to reduce the risk of tooth fracture, which is a common reason for tooth mortality.[23] An epidemiological study by Salehrabi et al.[24] assessed the outcome of endodontic treatment and revealed that 85% of the root canal-treated extracted teeth had no full-coverage restorations. Another investigation by Shelley et al.[25] revealed that only 27% received the recommended full-coverage restoration. In patients who might not go for full-coverage restorations, the reduction of the occlusal contacts will result in loss of function of the tooth. On the contrary, it is also necessary to weigh the benefits of occlusion reduction which could result in prevention of flare-ups. Further studies are needed to conclude that flare-ups could result more often in the occlusion intact group than the occlusion relieved group.


  Conclusion Top


There was no statistically significant difference in the incidence of postoperative pain in between the groups. The pattern of postoperative pain did show a gradual reduction in the occlusion relieved group. Flare-ups were reported in the occlusion intact group. This suggests that occlusal reduction could play an important role in prevention of flare-ups during endodontic treatment.

Acknowledgment

The study was conducted in MM College of Dental Sciences and Hospital, Mullana, Ambala, when the authors were working in the institution.

We would like to thank Dr. Prabhakar Mishra, Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, for helping in the statistical analysis.

Ethical clearance

IEC/2014/04/434.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sathorn C, Parashos P, Messer H. The prevalence of postoperative pain and flare-up in single- and multiple-visit endodontic treatment: A systematic review. Int Endod J 2008;41:91-9.  Back to cited text no. 1
    
2.
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Jalalzadeh SM, Mamavi A, Shahriari S, Santos FA, Pochapski MT. Effect of pretreatment prednisolone on postendodontic pain: A double-blind parallel-randomized clinical trial. J Endod 2010;36:978-81.  Back to cited text no. 3
    
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Dunsky JL, Moore PA. Long-acting local anesthetics: A comparison of bupivacaine and etidocaine in endodontics. J Endod 1984;10:457-60.  Back to cited text no. 4
    
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Rosenberg PA. Clinical strategies for managing endodontic pain. Endod Topics 2002;3:78-92.  Back to cited text no. 5
    
6.
Gatewood RS, Himel VT, Dorn SO. Treatment of the endodontic emergency: A decade later. J Endod 1990;16:284-91.  Back to cited text no. 6
    
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Natkin E. Treatment of endodontic emergencies. Dent Clin North Am 1974;18:243-55.  Back to cited text no. 7
    
8.
Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on pain after endodontic instrumentation. J Endod 1998;24:492-6.  Back to cited text no. 8
    
9.
Creech JL 3rd, Walton RE, Kaltenbach R. Effect of occlusal relief on endodontic pain. J Am Dent Assoc 1984;109:64-7.  Back to cited text no. 9
    
10.
Jostes JL, Holland GR. The effect of occlusal reduction after canal preparation on patient comfort. J Endod 1984;10:34-7.  Back to cited text no. 10
    
11.
Parirokh M, Rakhbi AR, Ashowi R, Nakhaee N, Abbott PV, Gorjestani H. Effect of occlusal reduction on postoperative pain in teeth with irreversible pulpitis and mild tenderness to percussion. J Endod 2013;39:1-4.  Back to cited text no. 11
    
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Heft MW, Parker SR. An experimental basis for revising the graphic rating scale for pain. Pain 1984;19:153-61.  Back to cited text no. 12
    
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Averbuch M, Katzper M. Assessment of visual analogue versus categorical scale for measurement of osteoarthritis. Pain J Clin Pharmacol 2004;44:368-72.  Back to cited text no. 13
    
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Antrim DD, Bakland LK, Parker MW. Treatment of endodontic urgent care cases. Dent Clin North Am 1986;30:549-72.  Back to cited text no. 14
    
15.
Dorn SO, Moodnik RM, Feldman MJ, Borden BG. Treatment of the endodontic emergency: A report based on a questionnaire. Part I. J Endodon 1977;3:94-100.  Back to cited text no. 15
    
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Dorn SO, Moodnik RM, Feldman MJ, Borden BG. Treatment of the endodontic emergency: A report based on a questionnaire. Part I1. J Endodon 1977;3:153-6.  Back to cited text no. 16
    
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Law A, Messer H. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. J Endod 2004;30:689-94.  Back to cited text no. 17
    
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Sathorn C, Parashos P, Messer H. Antibacterial efficacy of calcium hydroxide intracanal dressing: A systematic review and meta-analysis. Int Endod J 2007;40:2-10.  Back to cited text no. 18
    
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Naidorf IJ. Endodontic flare-ups: Bacteriological and immunological mechanisms. J Endod 1985;11:462-4.  Back to cited text no. 19
    
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Seltzer S, Naidrof IJ. Flare ups in endodontics.I>etiological factors. J Endod 1985;11:472-8.  Back to cited text no. 20
    
21.
Kuştarci A, Akpinar KE, Er K. Apical extrusion of intracanal debris and irrigant following use of various instrumentation techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:257-62.  Back to cited text no. 21
    
22.
Morgan LF, Montgomery S. An evaluation of the crown-down pressureless technique. J Endod 1984;10:491-8.  Back to cited text no. 22
    
23.
Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent 2002;87:256-63.  Back to cited text no. 23
    
24.
Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: An epidemiological study. J Endod 2004;30:846-50.  Back to cited text no. 24
    
25.
Shelley PQ, Johnson BR, BeGole EA. Use of an electronic patient record system to evaluate restorative treatment following root canal therapy. J Dent Educ 2007;71:1333-9.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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