Postoperative pain after root-end resection and filling

doi:10.1016/j.tripleo.2005.01.010

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology

Volume 100, Issue 6, December 2005, Pages 762-766

https://doi.org/10.1016/j.tripleo.2005.01.010 Get rights and content

Objective

To evaluate the pain experience following root-end resection and filling with Mineral Trioxide Aggregate or Intermediate Restorative Material.

Study design

Referred adult patients recruited using strict entry criteria were randomly allocated to receive either material. A standardized surgical technique was employed. Postoperative instructions and a pain questionnaire were given to each patient to record the severity of their pain at 3 time intervals—3-5 hours, 24 hours, and 48 hours after surgery—on a standard visual analog scale (VAS). Patients were also asked to record consumption of any self-prescribed analgesics, the type, and dosage.

Results

At 3-5 hours after surgery, regardless of the material used, 90% of all patients experienced some level of postoperative pain. Twenty-four hours after surgery 82% of patients experienced pain, as did 72% after 48 hours. Thirty-seven percent of patients did not take any analgesics at all. In order of popularity, the analgesics taken were ibuprofen, acetaminophen, and acetaminophen plus codeine phosphate. The VAS measurements were reduced over time in both treatment groups (P < .001). There was no statistically significant difference in the proportion of subjects taking analgesics in each treatment group. Patients who used analgesics showed higher median VAS measurements at all time periods (P < .05).

Conclusions

There was no significant difference in the pain experienced by both treatment groups. The postoperative pain was of a relatively short duration, at its maximum intensity early in the postoperative period but progressively decreased with time. Even if pain relief medication was needed, nonprescription analgesics were adequate and effective.

Section snippets

Material and methods

An account of the methods has been described previously¹¹ but is repeated here. Adult patients who were referred for root-end resection and filling were invited to participate. Approval was obtained from the local ethical committee. Each patient was given written advice about the study and the follow-up care necessary; they were also given the opportunity to withdraw. A consent form was signed if they agreed to participate in the study. There was no financial inducement to participate. The

Results

A full breakdown on the flow of patients through this study is shown in Table I. The number of surgical procedures performed was 198. A total of 100 pain questionnaires (54 in IRM group, 46 in MTA group) were deemed correctly completed. Others were not returned or were excluded if the writing was illegible or the information entered was incomplete. No patient returned or telephoned because of severe pain. Because there was no difference in the male-to-female ratio and their related VAS

Discussion

The VAS, as used in this study, is a standard pain measurement technique based on the theory that pain intensity is continuous, without jumps or intervals. Other pain measurement techniques such as verbal rating or numerical descriptive scales may not adequately reflect the changes produced within this variable. Within the boundaries of the VAS line respondents can mark the extent of their pain providing a quantitative measurement. Thus respondents are presented with a rating system with

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Cited by (28)

Severe Pain after Endodontic Surgery: An Analysis of Incidence and Risk Factors
2021, Journal of Endodontics
The aim of this study was to determine the prevalence and characteristics of postoperative pain after endodontic microsurgery and to identify potential predictors for severe pain.
One hundred seventy-three patients who underwent endodontic microsurgery at a private practice were included in the study. The patients were asked to fill out a questionnaire to assess their postoperative pain levels for 5 days after surgery. The questionnaires were analyzed to record the changes in pain levels over time. The presence and size of preoperative lesions and bone thickness were determined on preoperative cone-beam computed tomographic scans. Statistical analyses were performed to identify predictors for developing severe pain after surgery. A binary logistic regression model was established to predict the occurrence of severe pain.
Severe pain was most prevalent on day 1 (17.3%) and gradually decreased until a small increase on day 5. The average pain level also peaked on day 1 postoperatively and gradually decreased afterward. No significant difference was observed between patients who reported severe pain and those who did not report severe pain regarding tooth position (anterior vs posterior), lesion size, and presence of fenestration. However, sex, age, and bone thickness were all significant predictors of severe postoperative pain, with odds ratios of 2.8, 0.96, and 1.41, respectively.
Severe pain was reported only in a small number of patients after endodontic microsurgery. Younger patients, females, and patients with thicker bone covering the apex are significantly more likely to develop severe pain.
Periapical Microsurgery: The Effects of Locally Injected Dexamethasone on Pain, Swelling, Bruising, and Wound Healing
2016, Journal of Endodontics
Citation Excerpt :
In contrast, others have claimed that over-the-counter medication is sufficient for pain relief after apical microsurgery. Chong and Pitt Ford (29) have shown that 37% of the patients did not require medication at any interval, and Christiansen et al (21) presented low pain rates after periapical microsurgery with the majority of the patients controlling pain by using ibuprofen. The latter study concluded that swelling was more related to patient complaint than pain.
The purpose of this prospective, double-blind, randomized clinical trial was to evaluate the postoperative healing of endodontic periapical microsurgery after local administration of dexamethasone.
Sixty patients were divided into 2 groups. The dexamethasone group received a single local submucosal injection of 4 mg dexamethasone, and the placebo group received a submucosal injection of saline solution at the conclusion of standardized periapical microsurgery. Acetaminophen and hydrocodone/acetaminophen were prescribed for pain relief. A Likert-like 6-point scale was used for self-evaluation of pain, bruising, swelling, and wound healing at 24, 48, 72, 96 hours and at 1 week. The number of tablets taken was registered. Data were analyzed using the chi-square and Fisher exact tests at a significance level of P < .05.
No improvements in pain, bruising, and wound healing were registered at any time interval. No difference was found in the number of tablets taken for pain relief. Subjects who received the dexamethasone injection reported less swelling 24 hours after periapical microsurgery (P < .05) but showed no significant benefit for the longer follow-up periods.
This study shows that a 4-mg dose of dexamethasone administered through a local submucosal injection after periapical microsurgery has minimal impact on pain, bruising, and apparent wound healing at any time over a 7-day interval, and the impact on swelling seems limited.
Mineral Trioxide Aggregate: A Comprehensive Literature Review-Part III: Clinical Applications, Drawbacks, and Mechanism of Action
2010, Journal of Endodontics
Mineral trioxide aggregate (MTA) has been recommended for various uses in endodontics. Two previous publications provided a comprehensive list of articles from November 1993–September 2009 regarding the chemical and physical properties, sealing ability, antibacterial activity, leakage, and biocompatibility of MTA. The purpose of Part III of this literature review is to present a comprehensive list of articles regarding animal studies, clinical applications, drawbacks, and mechanism of action of MTA.
A review of the literature was performed by using electronic and hand-searching methods for the clinical applications of MTA in experimental animals and humans as well as its drawbacks and mechanism of action from November 1993–September 2009.
MTA is a promising material for root-end filling, perforation repair, vital pulp therapy, and apical barrier formation for teeth with necrotic pulps and open apexes. Despite the presence of numerous case reports and case series regarding these applications, there are few designed research studies regarding clinical applications of this material. MTA has some known drawbacks such as a long setting time, high cost, and potential of discoloration. Hydroxyapatite crystals form over MTA when it comes in contact with tissue synthetic fluid. This can act as a nidus for the formation of calcified structures after the use of this material in endodontic treatments.
On the basis of available information, it appears that MTA is the material of choice for some clinical applications. More clinical studies are needed to confirm its efficacy compared with other materials.
Prognostic factors in apical surgery with root-end filling: A meta-analysis
2010, Journal of Endodontics
Citation Excerpt :
The remaining 140 clinical articles were screened for data on prognostic factors. An additional 102 articles had to be excluded for the following reasons: (i) the apical surgery did not include the placement of a root-end filling or the study included various surgical procedures (14–39); (ii) the study did not give details about prognostic factors related to periapical healing or the study assessed an outcome other than periapical healing (40–74); (iii) only one category of a specific prognostic factor had been assessed (ie, there was no comparison of two or more categories; eg, only males instead of males vs females) (75–99); (iv) two categories of a prognostic factor had been assessed, but only a single study provided data on this prognostic factor (100–106); (v) same study published in other language or same material published in a previous article with a shorter follow-up (107–112); and (vi) study excluded for other reason (113–115). The final number of included clinical studies was 38 (Table 1).
Apical surgery has seen continuous development with regard to equipment and surgical technique. However, there is still a shortage of evidence-based information regarding healing determinants. The objective of this meta-analysis was to review clinical articles on apical surgery with root-end filling in order to assess potential prognostic factors.
An electronic search of PubMed and Cochrane databases was performed in 2008. Only studies with clearly defined healing criteria were included, and data for at least two categories per prognostic factor had to be reported. Prognostic factors were divided into patient-related, tooth-related, or treatment-related factors. The reported percentages of healed teeth (“the healed rate”) were pooled per category. The statistical method of Mantel-Haenszel was applied to estimate the odds ratios and their 95% confidence intervals.
With regard to tooth-related factors, the following categories were significantly associated with higher healed rates: cases without preoperative pain or signs, cases with good density of root canal filling, and cases with absence or size ≤5 mm of periapical lesion. With regard to treatment-related factors, cases treated with the use of an endoscope tended to have higher healed rates than cases without the use of an endoscope.
Although the clinician may be able to control treatment-related factors (by choosing a certain technique), patient- and tooth-related factors are usually beyond the surgeon's power. Nevertheless, patient- and tooth-related factors should be considered as important prognostic determinants when planning or weighing apical surgery against treatment alternatives.
Patient discomfort following periapical surgery
2008, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology
Citation Excerpt :
In general, patients reported to have ingested few tablets during the first postoperative days. A previous study found that if analgesics were needed postoperatively, then self-prescribed tablets were adequate and effective.3 In the present study, oral awareness was the most frequently reported reason for postoperative discomfort followed by swelling, compromised chewing ability, and pain.
The aim of the study was to assess patient discomfort following periapical surgery.
Forty-two patients with apical periodontitis were allocated to apicectomy with either smoothening of the gutta-percha root filling or a retrograde root filling with mineral trioxide aggregate (MTA).
Pooling all patients, VAS score for pain peaked 3 hours postoperatively (mean VAS = 29). The VAS score for swelling peaked 1 day postoperatively (mean VAS = 41). Patients’ overall perception of postoperative discomfort was induced by (questions asked at the day for suture removal): Oral awareness (36 yes, 6 no); swelling (30 yes, 12 no); compromised chewing ability (18 yes, 24 no); pain (15 yes, 27 no). There was no correlation between the operating time and VAS scores for pain and swelling (r ≤ .25, P > .11).
Patients experienced little pain and moderate swelling after periapical surgery. Oral awareness was the most reported reason for postoperative discomfort. The operating time was not a decisive factor in relation to postoperative discomfort.
Microscopic Periradicular Surgery: Perioperative Predictors for Postoperative Clinical Outcomes and Quality of Life Assessment
2007, Journal of Endodontics
Citation Excerpt :
Nevertheless, this factor may also have contributed to the lower degree of postoperative pain and swelling reported in this study. The present study supports previous findings (7, 9–13) that, on average, maximum pain is experienced on the night of the surgery and maximum swelling is experienced on day 1 of the surgery and pain and swelling improve over time after the surgical procedure. Our results also show that patients are more likely to experience swelling than pain.
The authors report on data from a self-assessment questionnaire filled out by 199 patients undergoing periradicular microscopic surgery at two private endodontic offices and at graduate endodontic clinics of the University of Pennsylvania. Regression analysis was performed using pain and swelling as dependent variables and age, sex, type of teeth, location, periapical lesion, and remedication as independent variables. Pain and swelling were significantly related to females and younger patients (p < 0.05). The results supported Etodolac as a pre- and postoperative analgesic and use of antibiotics restricted to high-risk patients. Maximum pain and swelling were reported at night and day 1 of the surgery, respectively. Generally, swelling was more often reported than pain. Surgeries in anterior maxilla were related to more pain and swelling. A majority of the patients (67%) rated surgical endodontics more pleasant than expected and found it less painful (46%) or the same (38%) as nonsurgical treatment. The results also point out that patients in general have negative beliefs and limited knowledge about periradicular surgery.

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: This work received funding from DHSC–London, Research & Development, Responsive Funding Programme.

View full text

EndodontologyPostoperative pain after root-end resection and filling

Objective

Study design

Results

Conclusions

Section snippets

Material and methods

Results

Discussion

Evaluation of NSAIDs for treating post-endodontic pain

Endod Topics

A comparison of pain levels during pulpectomy, extractions, and restorative procedures

J Endod

Prevalence of and factors affecting postpreparation pain in patients undergoing two-visit root canal treatment

Int Endod J

The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study

Int Endod J

Retreatment versus initial root canal treatment: factors affecting posttreatment pain

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Postoperative pain after apicectomy. A clinical investigation

Int Endod J

Postoperative discomfort associated with surgical and nonsurgical endodontic retreatment

Endod Dent Traumatol

Endodontology
Postoperative pain after root-end resection and filling