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HOME > Restor Dent Endod > Volume 46(3); 2021 > Article
Research Article Postoperative pain after endodontic treatment of necrotic teeth with large intentional foraminal enlargement
Ricardo Machado1orcid, Daniel Comparin2orcid, Sérgio Aparecido Ignácio3orcid, Ulisses Xavier da Silva Neto3orcid
Restor Dent Endod 2021;46(3):e31.
DOI: https://doi.org/10.5395/rde.2021.46.e31
Published online: May 31, 2021

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Correspondence to Ricardo Machado, DDS, MSc, PhD. Post-Doctorate Student, Department of Endodontics, School of Health and Bioscience, Pontifical Catholic University of Paraná, – PUC/PR, Rua Imaculada Conceição, 1155, Prado Velho, 80.215-901, Curitiba, Paraná, Brazil. ricardo.machado.endo@gmail.com
• Received: July 13, 2020   • Revised: December 17, 2020   • Accepted: December 31, 2020

Copyright © 2021. The Korean Academy of Conservative Dentistry

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Objectives
    To evaluate postoperative pain after endodontic treatment of necrotic teeth using large intentional foraminal enlargement (LIFE).
  • Materials and Methods
    The sample included 60 asymptomatic necrotic teeth (with or without chronic apical periodontitis), and a periodontal probing depth of 3 mm, previously accessed and referred to perform endodontic treatment. After previous procedures, the position and approximate size of the apical foramen (AF) were determined by using an apex locator and K flexo-files, respectively. The chemomechanical preparation was performed with Profile 04 files 2 mm beyond the AF to achieve the LIFE, using 2.5 mL of 2.5% NaOCl at each file change. The filling was performed by Tagger's hybrid technique and EndoFill sealer. Phone calls were made to all the patients at 24, 48 and 72 hours after treatment, to classify postoperative pain. Statistical analysis was performed by different tests with a significance level of 5%.
  • Results
    Age, gender, periradicular status and tooth type did not influence postoperative pain (p > 0.05). Only 1 patient (1.66%) reported severe pain after 72 hours. Moderate pain was reported by 7, 4 and 3 patients after 24, 48 and 72 hours, respectively (p = 0.0001). However, paired analyses showed a statistically significant difference only between 24 and 72 hours (p = 0.04). Sealer extrusion did not influence the postoperative pain (p > 0.05).
  • Conclusions
    Acute or moderate postoperative pain was uncommon after endodontic treatment of necrotic teeth with LIFE.
  • Trial Registration
    The Brazilian Clinical Trials Registry Identifier: RBR-3r967t
  • Keywords: Endodontic treatment; Foraminal enlargement; Postoperative pain; Pulp necrosis
Endodontic treatment aims to maintain or reestablish the health of periapical tissues by cleaning and filling the root canals [1,2]. Biomechanical preparation and intracanal dressing (when used) are responsible for the disinfection process; however, they are not able to eliminate the content of the root canal system completely due to its anatomical and morphological complexity and to the resistance of some microorganisms involved in endodontic infection [3,4].
Molecular analysis has shown the presence of bacterial biofilms in apical foramen (AF) [5,6,7]. This is why the impact of intentional foraminal enlargement (IFE) on the success of endodontic treatment has been studied [8,9,10].
IFE is based on the mechanical enlargement of the AF to reduce the bacterial load by excising the infected cementum and dentin from this area [9,10]. However, a study performed by Tinaz et al. [11] showed that IFE caused greater debris extrusion, which is one of the main reasons for postoperative pain after endodontic treatment of necrotic teeth [12,13].
Several randomized clinical trials have evaluated postoperative pain after performing endodontic treatments of necrotic teeth using manual, rotary and reciprocating files to conduct IFE, and have found different results [14,15,16]. Silva et al. [16] carried out endodontic treatments of necrotic anterior teeth with or without IFE using hand files. The authors reported similar levels of postoperative pain between these groups. Cruz Junior et al. [15] conducted a similar analysis in the single-rooted necrotic tooth using a reciprocating system. Patients from the IFE group reported more pain after 24 hours.
It is noteworthy to mention that the AF frequently has an oval shape [17,18,19]. Therefore, it might be cleaned better with large IFE (LIFE) [10,20]. To the best of our knowledge, no study has yet been made to evaluate postoperative pain after performing endodontic treatment with LIFE in necrotic teeth (with or without chronic apical periodontitis). Therefore, this was the purpose of this study.
This study received approval from the Human Research Ethics Committee of the Pontifical University of Paraná – PUC/PR (CAAE. 12449019.6.0000.0020), is reported in accordance with the Consolidated Standards of Reporting Trials Statement (CONSORT, 2010), and is registered at The Brazilian Registry of Clinical Trials (ReBEC; RBR-3r967t).
Sample size calculation
The sample size to validate the results of this research was determined by conducting a pilot study that showed that less than 5% of the patients reported significant postoperative pain (acute or moderate) after treatment. The proportion-sampling method was used to determine the sample size, which was set at 60 teeth, considering a confidence level of 95% and a maximum margin of error of 5.5%.
Case selection
This study was conducted in patients ranging in age from 14 to 73 years, referred to the Centro de Especialidades Odontológicas de Navegantes, Santa Catarina, Brazil, to perform endodontic treatment, between September and October 2019. The patients were informed about the postoperative care, the clinical and radiographic examinations, and the available alternative treatment options. Information about the study and the treatment protocol were provided to all the patients or their caregivers (for patients under 18 years old), and written consent was obtained.
The inclusion criteria for this study were asymptomatic necrotic teeth (with and without chronic apical periodontitis), and a periodontal probing depth of 3 mm at most, as previously accessed at the Public Basic Health Units of the aforementioned city. The exclusion criteria were consumption of anti-inflammatories, analgesics of any type, or antibiotics within the last 10 days before treatment, presence of root resorption, sinus tracts, trismus, periodontal probing greater than 3 mm, systemic diseases, history of trauma, pregnancy, severe malocclusion associated with traumatic occlusion, lack of patient compliance and history of intolerance to nonsteroidal anti-inflammatory drugs.
Treatment protocol
After clinical and radiographic examination of the patients, and evaluation of their health status, the teeth were anesthetized using 2% mepivacaine with epinephrine 1:100,000 (Mepiadre; DFL Indústria e Comércio S.A., Rio de Janeiro, RJ, Brazil). After rubber dam placement and disinfection, the temporary restoration was removed using a 1014 or 1016 HL bur (KG Sorensen, Barueri, SP, Brazil). When reaching the pulp chamber, copious irrigation was performed with 5 mL 2.5% sodium hypochlorite (NaOCl) (Fórmula & Ação, São Paulo, SP, Brazil), and the canals were flooded continuously with irrigation solution from a NaviTip 31 G needle (Ultradent, South Jordan, UT, USA). Initial exploration was performed with a size 15 K Flexo-File (Dentsply-Maillefer, Ballaigues, Switzerland). Cervical and middle thirds were prepared with Orifice Shapers (Dentsply-Maillefer) driven by an X-Smart Plus motor (Dentsply-Maillefer). Afterward, the position of the AF was established by size 10 or larger K Flexo-Files (Dentsply-Maillefer) coupled to an apex locator (Root ZX II, J Morita, Kyoto, Japan), and confirmed by radiographs. The approximate size of the AF was determined by using K Flexo-Files size 10, 15, 20, 25 or 30 (Dentsply-Maillefer). This strategy was crucial for the instrumentation planning of similar LIFE procedures performed to treat different teeth (Table 1).
Table 1

Instrumentation planning for similar large intentional foraminal enlargement (LIFE) to treat different teeth

Approximate size of AF before instrumentation (corresponding to the manual Flexo-File number) Final file used 2mm beyond the AF (tip/taper) Approximate size of AF after instrumentation (corresponding to D2 of the final file used)
10 30.04 38
15 35.04 43
20 40.04 48
25 45.04 53
30 60.04 68
AF, apical foramen.
Chemomechanical preparation was performed by using Profile 04 files (Dentsply-Maillefer) driven by the same motor mentioned above, using a crown-down approach. A 2.5 mL aliquot of 2.5% NaOCl was used as an irrigating solution at each file change, applied with a NaviTip 31 G (Ultradent) needle up to 5 mm short of the AF, as established by rubber stops. All the teeth received the same amount of irrigant.
After instrumentation, the canals were flooded with 3 mL of 17% ethylenediaminetetraacetic acid (Fórmula & Ação) for 3 minutes. A final flush with 5 mL of saline solution was performed, and the canals were dried with absorbent paper points (Dentsply-Maillefer). For each canal, the main cone corresponding to the last instrument used during chemomechanical preparation was calibrated and stabilized to approximately 1.5 mm from the AF to avoid overextension. After radiographic analysis of the level of the main cone, the root canal filling was performed by Tagger's hybrid technique and Endofill sealer (Dentsply-Maillefer), and the temporary restoration, with Cavitec (Caitech, São José dos Pinhais, PR, Brazil) or Cimpat (Septodont, São Paulo, SP, Brazil). A final radiograph was taken after occlusal adjustment (Figure 1), after which the patients were referred back to the Public Basic Health Unit of origin to receive the definitive restorations. No medication was prescribed, and the patient was instructed to take either paracetamol (750 mg every 6 hours) or ibuprofen (600 mg every 6 hours) if feeling pain [15]. All the treatments were performed by a single and experienced operator (R.M).
Figure 1

Examples of final radiographs.

rde-46-e31-g001.jpg
Analysis of postoperative pain and statistical analysis
The assessment of postoperative pain was conducted at 24, 48 and 72 hours after the treatments, as outlined below. Phone calls were made for all the patients to inquire into their pain. The postoperative pain was classified according to a score based on a verbal categorization (Table 2) [16,21].
Table 2

Scores and features of the pain

Score Pain Features
0 No pain The patient felt well.
1 Slight pain The patient could be distracted from feeling pain, and no analgesic was required.
2 Moderate pain The patient felt moderate pain even while concentrating on some other activity, and an analgesic was required.
3 Severe pain The patient was no longer able to perform any type of activity, and needed to lie down and rest (analgesics had little or no effect on relieving the pain).
The findings were recorded on an Excel spreadsheet (Microsoft Corp., Redmond, WA, USA) for statistical evaluation with SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Kolmogorov-Smirnov's test was used to evaluate the normality of data. Kruskal-Wallis, Mann-Whitney U, χ2, Friedman's analysis of variance and Friedman's multiple 2 to 2 comparison tests were used to determine significant any difference among the variables (p < 0.05).
Demographic data are being shown in Table 3. General incidence and levels of postoperative pain at the time points are shown in Figure 2. There was a tendency for the postoperative pain to decrease over time (p = 0.0001). However, paired analyses showed a statistically significant difference only between 24 and 72 hours (p = 0.04). Age, gender, periradicular status, tooth type and sealer extrusion did not influence the postoperative pain, regardless of time (p > 0.05) (Tables 4, 5, 6).
Table 3

Demographic data

Characteristics Men Women Total
No. of patients 28 32 60
Age (mean ± standard deviation) 37.86 ± 18.55 38.38 ± 15.29 -
Periradicular status Without lesion: 3 Without lesion: 9 12
With lesion: 25 With lesion: 23 48
Tooth
Maxillary canine 1 2 3
Mandibular central incisor 4 0 4
Maxillary central incisor 3 4 7
Mandibular lateral incisor 1 0 1
Maxillary lateral incisor 0 1 1
First mandibular molar 3 5 8
First maxillary molar 2 3 5
First mandibular premolar 1 1 2
First maxillary premolar 3 3 6
Second mandibular molar 0 1 1
Second maxillary molar 4 0 4
Second mandibular premolar 2 5 7
Second maxillary premolar 4 7 11
Figure 2

Incidence and levels of postoperative pain after 24, 48 and 72 hours.

rde-46-e31-g002.jpg
Table 4

Postoperative pain considering time and age, gender, periradicular status, and tooth type

Characteristics Time (after; hr) Subdivision Number Mean pain score Standard deviation p value
Age 24 < 30 years old 21 0.52 0.873 0.10*
≥ 30 and ≤ 50 years old 21 0.71 1.007
> 50 years old 18 0.11 0.323
48 < 30 years old 21 0.43 0.811 0.30*
≥ 30 and ≤ 50 years old 21 0.43 0.746
> 50 years old 18 0.11 0.323
72 < 30 years old 21 0.29 0.784 0.17*
≥ 30 and ≤ 50 years old 21 0.29 0.644
> 50 years old 18 0.00 0.000
Gender 24 Men 28 0.32 0.612 0.40†
Women 32 0.59 0.979
48 Men 28 0.25 0.518 0.62†
Women 32 0.41 0.798
72 Men 28 0.07 0.378 0.07†
Women 32 0.31 0.738
Periradicular status 24 Without lesion 12 0.50 0.790 0.72†
With lesion 48 0.46 0.840
48 Without lesion 12 0.50 0.790 0.32†
With lesion 48 0.29 0.650
72 Without lesion 12 0.33 0.770 0.50†
With lesion 48 0.17 0.550
Tooth type‡ 24 Maxillary canine 3 0.00 0.000 0.87*
Mandibular central incisor 4 0.50 1.000
Maxillary central incisor 7 0.71 0.951
First mandibular molar 8 0.50 1.069
First maxillary molar 5 0.60 0.894
First maxillary premolar 6 0.17 0.408
Second maxillary molar 4 0.50 0.577
Second mandibular premolar 7 0.71 1.254
Second maxillary premolar 11 0.27 0.647
48 Maxillary canine 3 0.00 0.000 0.81*
Mandibular central incisor 4 0.25 0.500
Maxillary central incisor 7 0.57 0.787
First mandibular molar 8 0.50 1.069
First maxillary molar 5 0.00 0.000
First maxillary premolar 6 0.17 0.408
Second maxillary molar 4 0.25 0.500
Second mandibular premolar 7 0.43 0.787
Second maxillary premolar 11 0.27 0.647
72 Maxillary canine 3 0.00 0.000 0.56*
Mandibular central incisor 4 0.00 0.000
Maxillary central incisor 7 0.43 0.787
First mandibular molar 8 0.38 1.061
First maxillary molar 5 0.00 0.000
First maxillary premolar 6 0.00 0.000
Second maxillary molar 4 0.00 0.000
Second mandibular premolar 7 0.43 0.787
Second maxillary premolar 11 0.18 0.603
*Value obtained from Kruskal-Wallis test; †Value obtained from Mann-Whitney U test; ‡Only tooth types with n. greater than 2 were used to analyze this variable.
Table 5

Postoperative pain considering time frame

Characteristics Comparative analysis (hr) Mean pain difference Standard error Test statistics p value*
Time frame 24 vs. 48 0.13 0.18 0.73 0.46
48 vs. 72 0.18 0.18 1.00 0.31
24 vs. 72 0.37 0.18 2.02 0.04
*Value obtained by Friedman's multiple 2 to 2 comparisons test.
Table 6

Postoperative pain considering sealer extrusion

Characteristics Time (after; hr) Occurrence of the event Number Mean pain score Standard deviation p value*
Sealer extrusion 24 No 36 0.25 0.50 0.07
Yes 24 0.79 1.10
48 No 36 0.19 0.46 0.10
Yes 24 0.54 0.88
72 No 36 0.08 0.36 0.07
Yes 24 0.38 0.82
*Value obtained from Mann-Whitney U test.
The root canal system of necrotic teeth is contaminated, including the AF. Considering that the recommended treatment involves removing the cause of the disease, IFE could promote better cleaning by improving the condition for tissue repair [10]. However, it has been suggested that even small patency files used through the apex may cause an acute periapical inflammatory response and severe postoperative pain [22]. Therefore, a common concern regarding IFE is the postoperative pain related to physical iatrogenic trauma in the periapical region [14,15,16,23]. However, the AF in most dental groups is oval-shaped; consequently, better cleaning of this region could be achieved with LIFE [10,17,18,19,20]. Up to now, the incidence and levels of postoperative pain have been evaluated only after performing endodontic treatments of necrotic teeth with IFE [14,15,16]. Hence, the aim of this study was to perform the same analysis with LIFE.
Assessment of the incidence and levels of postoperative pain after performing endodontic treatment is a challenge due to the complexity of the intervention [13,24,25,26]. Assuming preoperative pain is a strong predictor of postoperative pain, only symptom-free patients were included in this study. Single-visit endodontic treatments have led to the same postoperative pain and healing of periapical tissues as 2-visit treatments [27,28,29,30,31]. Therefore, all treatments were completed in a single visit, to minimize the number of procedures and variations of intracanal medication used [14,15,29]. However, endodontic accesses had already been performed in previous appointments. Finally, it has been considered that operator experience may influence the incidence of postoperative pain [32]. For this reason, all treatments were performed by the same operator [14,15,24].
Different methods have been used to assess pain after endodontic therapy, such as visual analog scales (VAS), scores based on verbal categorizations or both [15,33,34,35,36,37,38]. The design of the method is crucial and must ensure that the questions will be fully understood by the patients and easily interpreted by the researchers [16,39]. In the present study, a score was used to classify postoperative pain, based on verbal categorizations, as follows: no, slight, moderate, and severe/acute pain. These categories were understood straightforwardly by patients. A similar strategy was used in other studies [16,34,35,36,40].
Our results pointed out that age did not influence postoperative pain, thus corroborating the findings by Ng et al. [41] and Polycarpou et al. [42]. On the other hand, Ali et al. [40] showed a higher postoperative pain in older (41 to 65 years) compared with younger (15 to 40 years) patients. The probable reasons could be lower pain tolerance, less blood flow, and delayed healing. However, a direct comparison between our results and those obtained by the 3 previously cited studies [40,41,42] should be made with caution. The age difference between the upper and lower limits of the age groupings of the cited studies [40,41,42] was 10 years and 25 years. Herein, the limit was about 15 years. In addition, the number of patients in the study groups was very discrepant. In the study by Ng et al. [41] for example, 119 (28.7%) of the 415 patients were ≥ 40 and < 50 years old, and 8 (1.9%) were ≥ 80 years old. In the present study, 21 patients were < 30 years old, 21 patients were ≥ 30 and ≤ 50 years old, and 18 patients were > 50 years old, that is, a similar distribution of patients occurred herein regarding age.
Several studies have shown a higher prevalence of postoperative pain in females than males [13,34,40]. The biological discrepancy between men and women could explain why [43,44]. Moreover, comparing the difference between male and female reproductive and pelvic anatomies, females have an additional portal of entry of infection, thereby leading to possible local and distant hyperalgesia. Moreover, fluctuating female hormonal levels might be associated with changing levels of serotonin and noradrenaline, thus leading to increased pain prevalence in females during the menstrual period, and when receiving hormonal replacement therapy or taking oral contraceptives [13,40,41]. However, our results pointed to no gender-related difference in postoperative pain. A plausible explanation is that a similar number of men and women (28/32) having similar ages (37.86 ± 18.55/38.38 ± 15.29, respectively) were treated herein. Healthy middle-aged women are likely to be less subject to the side effects associated with the above physical factors, and may therefore have responses to pain corresponding to those of men [41,42].
The nature of the pulp and periapical status could modulate postoperative pain in endodontics. Teeth with nonvital pulps associated with periapical lesions are densely contaminated, and have an 83.2% prevalence of foraminal resorption [45]. In addition, disruption of the apical constriction by IFE causes greater debris extrusion, which is an important factor associated with postoperative pain [11,17]. Nevertheless, our results showed that postoperative pain was not influenced by periradicular status. Marshall and Liesinger [46] observed that patients with periapical lesions that could not be detected by radiograph had more postoperative pain than those who had such lesions detected by radiograph. Ng et al. [41] indicated that postoperative pain was less in teeth having large periapical lesions (> 3 mm), compared with teeth having smaller or no periapical lesions. Genet et al. [47] showed that postoperative pain was greater in teeth with periapical radiolucency greater than 5 mm in diameter. A periapical lesion from an endodontic infection might exist without being visible in the radiograph [48]. It can be detected radiographically only when it attains nearly 30%–50% of the bone mineral loss [49,50]. Other conditions, such as apical morphologic variations, surrounding bone density, X-ray angulations and radiographic contrast, also influence radiographic interpretation [51]. These factors may explain the conflicting results of the studies cited above and also the present findings [41,46,47].
Some studies showed that postoperative pain was more frequent and higher in posterior teeth [13,33,41]. This could be attributed to their more complex root canal anatomy [36]. Conversely, other studies pointed out that postoperative pain was not influenced by the tooth type [28,52,53]. In this study, tooth type also did not influence postoperative pain. As mentioned previously, an experienced operator (R.M) performed all the treatments. This could have decreased the impact of the root canal anatomy, thus contributing to the low incidence and levels of postoperative pain.
Overall, mean pain scores were low, and just one patient reported severe/acute pain after 72 hours (1.66%). Similar results were obtained by Relvas et al. [35] in the group where the chemomechanical preparation was performed by a rotary system (ProTaper Universal). We believe that the low incidence and levels of postoperative pain observed in our study are probably related to the same reasons found by Relvas et al. [35] namely: a) only teeth with asymptomatic pulp necrosis were treated; b) all teeth suffered occlusal adjustment after the treatment; and c) in regard to the irrigation protocol, the same volume of irrigant was used, and the needle was inserted at a distance far enough from the apex to prevent extrusion.
Moderate pain was reported by 7, 4 and 3 patients after 24, 48 and 72 hours, respectively, implying that there was a tendency for pain to decrease over time (p = 0.0001). However, paired analyses showed a statistically significant difference only between 24 and 72 hours (p = 0.04). These results are in line with those obtained by a prospective, randomized, double-blind clinical trial performed by Shokraneh et al. [54] and a systematic review and meta-analysis conducted by Pak and White [55]. Nonetheless, Yaylali et al. [14] observed more pain in the 48-hour post-treatment period. This contradictory result may be attributed to the different methodological designs between the last cited study [14] and the current research. In the study by Yaylali et al. [14] only necrotic molars with radiographically visualized periradicular lesions were treated. Chemomechanical preparation was performed by using ProTaper Next files after establishing the working length (WL) at the AF. The irrigation consisted of 2.5% NaOCl using a Max-i-Probe needle up to 2 mm short of the WL, and the postoperative pain was evaluated by VAS. The authors did not report the approximate size of the AF. In our clinical protocol, the WL was determined at 2 mm beyond the AF. After measuring the approximate size of the AF with manual files, chemomechanical preparation was performed by using Profile 04 files to conduct the LIFE. Irrigation was performed with 2.5% NaOCl using a NaviTip needle up to 5 mm short of the AF, and the postoperative pain was evaluated with a score based on a verbal categorization.
Oxidative stress and, more specifically, reactive oxygen species (ROS) have been found to be linked to inflammatory pain in vivo [56,57]. A recent study showed that the production of ROS increased 4- to 7-fold when the human pulp cells were treated with root canal sealers in vitro [58]. This led the authors of the present study to evaluate the relationship between postoperative pain and sealer extrusion; however, no correlation was observed. According to Sadaf and Ahmad [28], clinical symptoms are associated with the composition and amount of the extruded sealer. Cintra et al. [59] showed that Endofill had the least favorable characteristics regarding cell viability, compared with Sealer Plus, AH Plus, Endofill, and SimpliSeal. Furthermore, in the histologic analysis, severe inflammation was observed at 7 days, characterized by multinucleated giant cells, and most specimens presented severe inflammation even after 30 days. These results can be explained by the presence of eugenol, which was also responsible for the strong antimicrobial action of this sealer [60]. Endofill was used in the present study, but only slight sealer extrusion occurred in 24 cases, and did not have a significant influence on postoperative pain over time (p > 0.05) [28].
The incidence and levels of postoperative pain after performing endodontic treatments in necrotic teeth with LIFE were low and not influenced by gender, age, tooth type, periradicular status or sealer extrusion. When postoperative pain did occur, it tended to decrease over time.

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

Author Contributions:

  • Conceptualization: Machado R.

  • Data curation: Machado R, Comparin D.

  • Formal analysis: Ignácio SA.

  • Funding acquisition: Machado R.

  • Investigation: Machado R.

  • Methodology: Machado R.

  • Project administration: Silva Neto UX.

  • Resources: Machado R.

  • Software: Machado R, Ignácio SA.

  • Supervision: Silva Neto UX.

  • Validation: Ignácio SA.

  • Visualization: Machado R.

  • Writing - original draft: Machado R, Comparin D.

  • Writing - review & editing: Silva Neto UX.

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REFERENCES

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      Postoperative pain after endodontic treatment of necrotic teeth with large intentional foraminal enlargement
      Restor Dent Endod. 2021;46(3):e31  Published online May 31, 2021
      DOI: https://doi.org/10.5395/rde.2021.46.e31
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    Figure
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    Postoperative pain after endodontic treatment of necrotic teeth with large intentional foraminal enlargement
    Image Image
    Figure 1 Examples of final radiographs.
    Figure 2 Incidence and levels of postoperative pain after 24, 48 and 72 hours.

    Figure 1

    Figure 2

    Postoperative pain after endodontic treatment of necrotic teeth with large intentional foraminal enlargement

    Instrumentation planning for similar large intentional foraminal enlargement (LIFE) to treat different teeth

    Approximate size of AF before instrumentation (corresponding to the manual Flexo-File number)Final file used 2mm beyond the AF (tip/taper)Approximate size of AF after instrumentation (corresponding to D2 of the final file used)
    1030.0438
    1535.0443
    2040.0448
    2545.0453
    3060.0468

    AF, apical foramen.

    Scores and features of the pain

    ScorePainFeatures
    0No painThe patient felt well.
    1Slight painThe patient could be distracted from feeling pain, and no analgesic was required.
    2Moderate painThe patient felt moderate pain even while concentrating on some other activity, and an analgesic was required.
    3Severe painThe patient was no longer able to perform any type of activity, and needed to lie down and rest (analgesics had little or no effect on relieving the pain).

    Demographic data

    CharacteristicsMenWomenTotal
    No. of patients283260
    Age (mean ± standard deviation)37.86 ± 18.5538.38 ± 15.29-
    Periradicular statusWithout lesion: 3Without lesion: 912
    With lesion: 25With lesion: 2348
    Tooth
    Maxillary canine123
    Mandibular central incisor404
    Maxillary central incisor347
    Mandibular lateral incisor101
    Maxillary lateral incisor011
    First mandibular molar358
    First maxillary molar235
    First mandibular premolar112
    First maxillary premolar336
    Second mandibular molar011
    Second maxillary molar404
    Second mandibular premolar257
    Second maxillary premolar4711

    Postoperative pain considering time and age, gender, periradicular status, and tooth type

    CharacteristicsTime (after; hr)SubdivisionNumberMean pain scoreStandard deviationp value
    Age24< 30 years old210.520.8730.10*
    ≥ 30 and ≤ 50 years old210.711.007
    > 50 years old180.110.323
    48< 30 years old210.430.8110.30*
    ≥ 30 and ≤ 50 years old210.430.746
    > 50 years old180.110.323
    72< 30 years old210.290.7840.17*
    ≥ 30 and ≤ 50 years old210.290.644
    > 50 years old180.000.000
    Gender24Men280.320.6120.40†
    Women320.590.979
    48Men280.250.5180.62†
    Women320.410.798
    72Men280.070.3780.07†
    Women320.310.738
    Periradicular status24Without lesion120.500.7900.72†
    With lesion480.460.840
    48Without lesion120.500.7900.32†
    With lesion480.290.650
    72Without lesion120.330.7700.50†
    With lesion480.170.550
    Tooth type‡24Maxillary canine30.000.0000.87*
    Mandibular central incisor40.501.000
    Maxillary central incisor70.710.951
    First mandibular molar80.501.069
    First maxillary molar50.600.894
    First maxillary premolar60.170.408
    Second maxillary molar40.500.577
    Second mandibular premolar70.711.254
    Second maxillary premolar110.270.647
    48Maxillary canine30.000.0000.81*
    Mandibular central incisor40.250.500
    Maxillary central incisor70.570.787
    First mandibular molar80.501.069
    First maxillary molar50.000.000
    First maxillary premolar60.170.408
    Second maxillary molar40.250.500
    Second mandibular premolar70.430.787
    Second maxillary premolar110.270.647
    72Maxillary canine30.000.0000.56*
    Mandibular central incisor40.000.000
    Maxillary central incisor70.430.787
    First mandibular molar80.381.061
    First maxillary molar50.000.000
    First maxillary premolar60.000.000
    Second maxillary molar40.000.000
    Second mandibular premolar70.430.787
    Second maxillary premolar110.180.603

    *Value obtained from Kruskal-Wallis test; †Value obtained from Mann-Whitney U test; ‡Only tooth types with n. greater than 2 were used to analyze this variable.

    Postoperative pain considering time frame

    CharacteristicsComparative analysis (hr)Mean pain differenceStandard errorTest statisticsp value*
    Time frame24 vs. 480.130.180.730.46
    48 vs. 720.180.181.000.31
    24 vs. 720.370.182.020.04

    *Value obtained by Friedman's multiple 2 to 2 comparisons test.

    Postoperative pain considering sealer extrusion

    CharacteristicsTime (after; hr)Occurrence of the eventNumberMean pain scoreStandard deviationp value*
    Sealer extrusion24No360.250.500.07
    Yes240.791.10
    48No360.190.460.10
    Yes240.540.88
    72No360.080.360.07
    Yes240.380.82

    *Value obtained from Mann-Whitney U test.
    Table 1 Instrumentation planning for similar large intentional foraminal enlargement (LIFE) to treat different teeth

    AF, apical foramen.

    Table 2 Scores and features of the pain

    Table 3 Demographic data

    Table 4 Postoperative pain considering time and age, gender, periradicular status, and tooth type

    *Value obtained from Kruskal-Wallis test; †Value obtained from Mann-Whitney U test; ‡Only tooth types with n. greater than 2 were used to analyze this variable.

    Table 5 Postoperative pain considering time frame

    *Value obtained by Friedman's multiple 2 to 2 comparisons test.

    Table 6 Postoperative pain considering sealer extrusion

    *Value obtained from Mann-Whitney U test.

    Table 1

    Table 2

    Table 3

    Table 4

    Table 5

    Table 6

    Restor Dent Endod : Restorative Dentistry & Endodontics
    © The Korean Academy of Conservative Dentistry.
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