Postoperative Pain in Multiple-visit and Single-visit Root Canal Treatment

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Postoperative Pain in Multiple-visit and Single-visit Root Canal Treatment
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  Postoperative Pain in Multiple-visit and Single-visit RootCanal Treatment  Abdel Hameed H. ElMubarak, BDS, MSc, Neamat H. Abu-bakr, BDS, DSS, MDSc, PhD,and Yahia E. Ibrahim, BDS, FFDRCSI   Abstract Introduction:  The purpose of the present study was toevaluate postoperative pain after root canal treatmentat the Department of Conservative Dentistry, Facultyof Dentistry, University of Khartoum, Sudan.  Methods: Two hundred thirty-four patients were included in thisstudy; age range was 18–62 years. Conventionalendodontic treatment was carried out in the includedteeth by the undergraduate dental students in a singlevisit or multiple visits. The chemomechanical prepara-tion of root canals was done bya modified double-flaredtechnique with combination of hand instruments. Post-operative pain was recorded by each patient by usingvisual analogue scale in well-defined categories at 2time intervals, 12 hours and 24 hours.  Results:  Datawere analyzed with the  c 2 test. The overall incidenceof postoperative pain was 9.0% after 12 hours and 24hours. Postoperative pain developed in 15.9% of thepatients with history of preoperative pain, whereas7.1% had postoperative pain among those withouthistory of preoperative pain. There was no significantdifference in postoperative pain between single-visitand multiple-visit root canal treatment (RCT).  Conclu-sions:  Within the limitations of the present study therewas a low incidence of postoperative pain afterconventional RCT. No significant difference exists inpostoperative pain after single-visit or multiple-visitRCT.  (J Endod 2010;36:36–39) Key Words Postoperative pain, root canal treatment, single andmultiple visit R oot canal treatment (RCT) or endodontic treatment is a common procedure indentistry. Postoperative pain is defined as pain of any degree that occurs after initi-ation of RCT, whereas flare-up has been defined as the onset or continuation of painand/or swelling after endodontic treatment. Flare-up is subset of postoperative pain(1). The development of postoperative pain after RCT is usually due to acute inflamma-tory response in the periradicular tissues. It commences within few hours or days afterendodontictreatment.Itisapoorindicatorofpathosisandunreliablepredictoroflong-term success (2–4).Patients might consider postoperative pain and flare-up as a benchmark against  which the clinician’s skills are measured. It might undermine patients’ confidence intheir dentists or patient satisfaction with the treatment.The etiologic factors in pain manifestation have not been determined precisely;however, several hypothetical mechanical, chemical, and/or microbial injuries to thepulp or the periradicular tissues might be involved. The development of pain ismoredependentontheintensityoftissuedamage,andtheoutcomeofRCTisinfluencedby the persistence of the source of injury  (5).Thebasicprinciples ofRCTaretheeradicationofrootcanalirritant,obturationof the root canal system, and preservation of the natural dentition. The procedure can bedone insinglevisitor multiplevisits (6). Itis directed toward the prevention and/ortheelimination of the pulpal periradicular microorganisms.InSudan,RCTisdoneinmultiplevisits.Sixtypercentofthepractitionerscompletethe treatment in more than 3 visits. One third of them perform the treatment in 3 visits,and5%completeitin2visits(7).Knowledgeaboutthecausesofpostoperativepainandadoption of appropriate preventive measures can significantly reduce the incidence of this highly distressing and undesirable clinical phenomenon (3). Patients and Methods Samples were obtained from patients attending or referred for RCT to the under-graduate clinics in the Department of Conservation, Faculty of Dentistry, University of Khartoum, Sudan. Two hundred thirty-four patients were included in this study; agerange was 18–62 years.Oral and written informed consent was obtained from the participants. Theprotocol and the informed consent forms were approved by the Postgraduate Faculty Board. Demographics, medical history, and dental history were recorded. Theseincludedthetoothtypeandlocationinthearch,periapicalcondition,andpulpalvitality based on pulp testing and direct clinical observation, history of preoperative pain, andnumber of RCT visits. Treatment Procedures Conventional RCT was carried out in the selected tooth by the undergraduatestudents.The treatment procedure was completedin eithersinglevisitor multiple visitsaccording to the complexity of the procedure. This was done irrespective of the pres-enceorabsenceofradiographicsignsofapicalpathosisorteethvitality.Only1toothforeach patient was treated. According to the medical history, an appropriate local anes-thetic solution (lidocaine 2% with adrenaline 1:80.000; INIBSA S, Barcelona, Spain) was used. High-speed and low-speed handpieces were used to gain coronal accessesto expose the canal orifices and remove loose dentin. The working length for the From the Conservative Dentistry Division, Department of Oral Rehabilitation, Faculty of Dentistry, University of Khar-toum, Khartoum, Sudan.Address requests for reprints to Dr Neamat Hassan Abu-bakr, BDS, DSS (Austria), MDSc (Scotland), PhD (Japan), Asso-ciate Professor and Head of Conservative Dentistry Division,Department of Oral Rehabilitation, Faculty of Dentistry, Univer-sityofKhartoum,P.O. Box102,Khartoum11111,Sudan.E-mailaddress: nhabubakr@uofk.edu.0099-2399/$0 - see front matterCopyright  ª  2010 by the American Association of Endodontists. All rights reserved.doi:10.1016/j.joen.2009.09.003 Clinical Research 36  ElMubarak et al.  JOE   —   Volume 36, Number 1, January 2010  root canals was considered to be at the apical constriction 1–2 mmfrom the radiographic apex by using parallel technique periapical radiographsandapexlocator(FormatronIV;DigitalApexLocator,Par-kell, NY). The chemomechanical preparation of root canals was by modified double-flared technique with combination of hand instru-ments (Diadent Group International Inc, Burnaby, Canada) and 2.5%NaOCl as an irrigating solution. Calcium hydroxide (Calpplus; Prevest Denpro Limited, Digiana Jummu, India) was used as an intracanal medicament in cases of multiple visits. Dentam (Scitem Limited,London, United Kingdom) was used as temporary restoration.Lateral cold condensation was the method used for obturation.Therootcanalsealantusedwaszincoxide–eugenolbase(Zical;Prevest Denpro Limited, Industrial Estate).Postoperative pain was measured by using a visual analogue scale(VAS)of1(nosymptom)to4(severepainand/orswelling)(8,9).VAS wastaughttotheparticipantsaswellasreportingthepostoperativeclin-ical conditions after 12 and 24 hours. Patients were contacted by tele-phone if they did not return the VAS form. The postoperative evaluation was recorded as none (no pain), slight pain (mild discomfort, need notreatment), moderate pain (pain relieved by analgesics), and severepain or flare-up(painand/or swellingnot relievedby simple analgesicsandrequiredunscheduledvisit).Allpatientsweregivenprescriptionfor500mgofacetaminophen,withthedoseof2tabletsevery8hourstakenonly if they experienced moderate pain.Software of Statistical Package for Social Sciences (SPSS Inc, Chi-cago, IL) was used to analyze the data at a confidence level of 95% by using c 2 test. Differences were considered significant when the proba-bilities were equal to or less than .05. Results Two hundred forty-four patients were included in the study. Tenpatientswereexcludedbecausetheyfailedtoshowup forpostoperativereviews after completion of the RCT.Of the 234 patients, 146 (62.4%) were women, and 88 (37.6%) weremen.Agerangewas18–62years.Ninety-six(41.0%)ofthetreatedteeth were in the maxilla, and 138 (59.0%) teeth were in the mandible.Eighty-six teeth (36.8%) were in the anterior segment. Eighty-threeteeth (35.5%) were premolars, and 65 (27.8%) were molars. Of the234 patients, 202 (86.3%) had been treated in multiple visits, and32 (13.7%) patients completed the RCT in a single visit.The overall incidence of postoperative pain after RCT during thefollow-upperiodof12and24hourswasassessedaccordingtopatient’srecord in the VAS. It showed slight differences; 208 patients (88.9%)developed no pain, 4 patients (1.7%) had mild pain, 1 patient (0.4%)hadmoderatepain,and21patients (9.0%)experienced severepostoperative pain after 12 hours (Fig. 1).The overall incidence of postoperative pain after RCT during thefollow-up period after 24 hours was as follows: 208 patients (88.9%)had no pain, 3 patients (1.3%) had mild pain, 2 patients (0.9%) hadmoderate pain, and 21 patients (9.0%) experienced severe postopera-tive pain (Fig. 2). When evaluating the incidence of postoperative pain in patients with history of preoperative pain, it was high in teeth with history of preoperative pain (15.9%) and appeared to be low (7.1%) in teeth without history of preoperative pain. The difference was significant (  P   = .048) (Table 1). Whenpostoperativepainwasassessedinrelationtotoothvitality,it  was found to be higher in nonvital teeth (13.7%) than in vital teeth(7.8%). The difference was significant (  P   = .049) (Table 2).RegardingthenumberofRCTvisits,29patients(90.6%)whoweretreated in single visit had no pain, and only 3 patients (9.4%) developedsevere pain. One hundred seventy-nine patients (88.6%) who were Figure 1.  Overall incidence of postoperative pain after RCT after 12 hoursaccording to VAS. Figure 2.  Overall incidence of postoperative pain after RCT after 24 hoursaccording to VAS. TABLE 1.  Occurrence of Postoperative Pain after RCT in Relation to History of Preoperative Pain History ofpreoperative painPain scale after 24 hNo pain Severe pain Total Yes, count (%) 103 (85.1) 18 (15.9) 121No, count (%) 105 (92.9) 8 (7.1) 113Total, count 208 26 234 Chi-square = 3.596;  P   = .048. TABLE 2.  Occurrence of Postoperative Pain after RCT in Relation to Tooth Vitality  Pain scale after 24 hPulpal diagnosis No pain Severe pain Total Vital teeth, count (%) 69 (93.2) 5 (7.8) 74Nonvital teeth, count (%) 138 (86.3) 22 (13.7) 160Total count 208 26 234 Chi-square = 3.567;  P   = .049. Clinical Research   JOE   —   Volume 36, Number 1, January 2010 Postoperative Pain after RCT  37  treatedinmultiplevisitshadnopain,and23patients(11.4%)hadseverepain. The difference in postoperative pain between single-visit andmultiple-visit RCT was not statistically significant (  P   = .737) (Table 3). Discussion Postoperative flare-up is the development of pain or swelling withinfewhoursordaysafterRCT.Thisisthefirststudytobeconductedin Sudan in a prospective manner to investigate the incidence of post-operative pain after RCT. There was standardization of the clinical parameters and uniformity in the evaluation of the results, which might minimize the operator-dependent variations.NumerousstudiesevaluatingthepostoperativepainafterRCThavebeen published, with the incidence of postoperative pain ranging from1.9%–48%, and they showed conflicting findings (10, 11).Inthepresentinvestigationoverallincidenceofpostoperativepainin RCT was 9%, keeping in mind that the treatment was carried out by undergraduate students. An observation that could be drawn from thisstudy is that when RCT is conducted under sound biologic principlesand by using contemporary scientifically based techniques, a low inci-dence of postoperative pain can be expected. Undergraduate studentsusually carry out RCT under supervision of endodontists, and they had enough time to complete the treatment procedures. Crown-downmodified double-flared technique deals with early coronal to apical flaring of the canals, which would decrease the potential of hydrostaticpressure being directed apically and avoiding passage of material andtissue debris intothe periapical tissues.Thus it is effective in preventionof postoperative pain (12).The incidence of postoperative pain associated with previously symptomatic teeth was 15.9%, compared with 7.1% for asymptomaticteeth (  P  # .05). This finding is in agreement with other studies (10,11, 13). This finding could be explained by the presence of infectionof the root canal system preoperatively. RCT involves several critical steps aimed to reduce infections of the root canal system; microorgan-ismsmightbeextrudedattheperiradiculartissuesorleftinsidetheroot canal, which could be responsible for postoperative inflammation andsymptoms.In the present study the occurrence of postoperative pain waspositively correlated to nonvital teeth (13.7%), compared with vital teeth (5.4%). This observation confirms the findings of the study done by Albashaireh and Alnegrish (14).On rare occasions, pulpal necrosis might initially be aseptic, but the necrotic tissues sooner or later become infected (15). Thus, vital teeth are less likely to be contaminated as in necrotic teeth, in whichmicroorganisms are more likely to spread to the periradicular tissue. Arias et al  (16) found that maintenance of apical patency does not increase the incidence, degree, or duration of postoperative pain when considering all variables together.On the other hand, different studies showed no correlationbetween vitality of the teeth and postoperative pain (2, 11, 17). Analysis of the influence of patient’s age, gender, tooth type andlocation, and periapical status of the treated teeth on postoperativepainshowedthatitishigherinyoungeragegroup18–33years,women,mandibular teeth, molars, and teeth with periapical radiolucency. Thedifference between the groups was not statistically significant. Thisresult appears to be similar to other studies (2, 10, 14, 18, 19).However, it disagrees with Ryan et al  (20), who presented gender(female)andtoothtype(molars)asfactorsthatsignificantlyinfluencedpostoperative pain.In the present study the incidence of postoperative pain insingle-visit RCT was 9.4%, and in multiple visits it was 11.4%, without significant difference. There were conflicting opinions with regard tothe influence of number of visits to perform RCT and postoperativepain. The finding of this study was comparable with other studies(2, 21). Other researchers found that the incidence of postoperativepain in multiple-visit RCT was significantly high (14, 17, 22), whereasanother study found high incidence in single-visit RCT (13). Figini et al  (23) found that no difference exists in the effectiveness of RCT interms of radiologic success between single-visit and multiple-visit treatments.In the present study most patients were treated in multiple visits(86.3%), and 13.7% were treated in a single visit. This might be dueto complexity of the procedure, fatigue of the patient or the operator,or the need to use calcium hydroxide intracanal medication betweenappointments. This was comparable to the study of Kane et al  (24), who reportedthat60% of the RCTs done bythe undergraduatestudents were performed in multiple visits, whereas Inamoto et al  (25) foundthat 55.8% of the endodontists completed RCT for vital teeth in single visit. A survey study done in Sudan stated that 95% of the practitionerscomplete RCT in more than 3 visits (7). References 1. Sathorn C. The prevalence of postoperative pain and flare-up in single- andmultiple-visit endodontic treatment: a systematic review. Int Endod J 2007;10:1–9.2. DiRenzo A, Gresla T, Johnson BR, Rogers M, Tucker D, BeGole EA. Postoperativepain after 1- and 2-visit root canal therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:605–10.3. Siqueira JF Jr., Microbial causes of endodontic flare-ups. Int Endod J 2003;36:453–63.4. Zuckerman O, Metzger Z, Sela G, Lin S. ‘‘Flare-up’’ during endodontic treatment:etiology and management. Refuat Hapeh Vehashinayim 2007;24:19–26, 69.5. Siqueira JF. Reaction of periradicular tissues to root canal treatment: benefits anddrawbacks. Endodontic Topics 2005;10(1):123–47.6. Torabinejad W. Principles and practice of endodontics. Philadelphia: Saunders;2002.7. Ahmed MF, Ibrahim YE. Root canal treatment in general practice in Sudan. Int En-dod J 2000;33:316–9.8. Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psycho-metric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain 2006;125:143–57.9. Bodian CA, Freedman G, Hossain S, Eisenkraft J, Beilin Y. The visual analog scale forpain: clinical significance in postoperative patients. Anesthesiology 2001;95:1356–61.10. Siqueira JF, Rocas IN, Fvieri A, et al. Incidence of postoperative pain after intracanal procedures based on antimicrobial strategy. J Endod 2002;28:457–8.11. John W, Harrison D, Baumgartner CJ, Timothy A. Incidence of pain associated clin-ical factors during and after root canal therapy. J Endod 1983;9:384–438.12. Goreva LA, Petrikas A. Postobturation pain associated with endodontic treatment.Stomatologiia (Mosk) 2004;83:14–6.13. Oginni AO, Udoye CI. Endodontic flare-ups: comparison of incidence between singleand multiple visit procedures in patients attending a Nigerian teaching hospital. BMCOral Health 2004;4:4.14. Albashaireh ZS, Alnegrish AS. Postobturation pain after single- and multiple-visit endodontic therapy: a prospective study. J Dent 1998;26:227–32.15. Bergenholtz LS. Controversies in endodontics. Crit Rev Oral Bio Med 2004;15:99–114.16. Arias A, Azabal M, Hidalgo J, De La Macorra J. Relationship between postendodonticpain, tooth diagnostic factors, and apical patency. J Endod 2009;35:189–92. TABLE 3.  Postoperative Pain in Relation to Number of RCT Visits Pain scale after 24 hRoot canal treatment No pain Severe pain Total Single visit, count(%) 29 (90.6) 3 (9.4) 32Multiple visits, count(%) 179 (88.6) 23 (11.4) 202Total, count(%) 208 (88.9) 26 (11.1) 234 Chi-square = 0.113;  P   = .737. Clinical Research 38  ElMubarak et al.  JOE   —   Volume 36, Number 1, January 2010  17. Roane JB, Dryden JA, Grimes EW. Incidence of postoperative pain after single- andmultiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol 1983;55:68–72.18. Imura N, Zuolo ML. Factors associated with endodontic flare-ups: a prospectivestudy. Int Endod J 1995;28:261–5.19. Ng YL, GlennonJP, SetchellDJ, GulabivalaK. Prevalenceof and factorsaffectingpost-obturation pain in patients undergoing root canal treatment. Int Endod J 2004;37:381–91.20. Ryan JL, Jureidini B, Hodges JS, Baisden M, Swift JQ, Bowles WR. Gender differencesin analgesia for endodontic pain. J Endod 2008;34:552–6.21. Pekruhn RB. Single-visit endodontic therapy: a preliminary clinical study. J Am Dent  Assoc 1981;103:875–7.22. Eleazer PD, Eleazer KR. Flare-up rate in pulpally necrotic molars in one-visit versustwo-visit endodontic treatment. J Endod 1998;24:614–6.23. Figini L, Lodi G, Gorni F. Gagliani. Single versus multiple visits for endodontic treat-ment of permanent teeth: a cochrane review. J Endod 2008;34:1041–7.24. Kane AW, Cisse D, Faye D, Toure B, Sarr M. Importance of the number of treatment sessions in the success of root canal therapy. Dakar Med 1999;44:109–13.25. Inamoto K, Kojima K, Nagamatsu K, Hamaguchi A, Nakata K, Nakamura H. A survey of the incidence of single-visit endodontics. J Endod 2002;28:371–4. Clinical Research   JOE   —   Volume 36, Number 1, January 2010 Postoperative Pain after RCT  39
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