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Managing Pain in the Endodontic Region

Pain is now widely recognized as a complex interaction of physical and psychological factors associated with actual or potential tissue damage. There is no question that pain often serves a useful protective function. For example, withdrawing from a hot stove or sharp object before significant injury can occur happens almost immediately and without conscious control. Children afflicted with congenital analgia (ie, congenital insensitivity to pain) experience frequent serious and often life-threatening injuries due to a complete absence of pain sensation. The value of tooth pain before, during, or after treatment is less obvious. Inflammatory mediators associated with pain may also be observed with wound healing, but it is clear that successful healing can occur without significant pain. The presence of pretreatment pain is often a valuable diagnostic aid, as hyperalgesia and allodynia associated with pulpal and periradicular inflammation allow more rapid and reliable identification of the source of the pain. The following presentation highlights several current techniques and strategies to manage pain related to endodontic treatment.

Is it possible to predict which patients are more likely to experience significant pain and therefore manage them more effectively? While quality evidence is lacking, several initial studies provide some guidance in this area. A consistent finding is that the presence of significant preoperative pain is a strong predictor of postoperative pain. Less certain predictors of postoperative pain include: presence of multiple allergies (ie, atopy), apprehension or anxiety, retreatment of a root canal, and a necrotic tooth with either a small periradicular lesion or none at all.1,2 Pretreatment with nonsteroidal anti-inflammatory drugs (NSAIDs)3,4 and the use of a long-acting local anesthetic5 are both useful strategies for reducing postoperative pain. Ibuprofen remains the standard NSAID for comparison purposes and is generally well tolerated by most patients. Clearly, a history of allergy or hypersensitivity to any NSAID or the presence of certain medical conditions (eg, active ulcers) would contraindicate the use of ibuprofen. Approximately 400 mg of ibuprofen is equivalent to 10 mg of morphine.6 A recent review of all commonly available oral analgesics found that 100% of patients taking 800 mg of ibuprofen had greater than 50% pain relief, and this analgesic had, overall, the lowest number needed to treat (NNT=1.6), even when compared to narcotic analgesics.7 An NSAID is most effective when given either preoperatively or immediately postoperatively rather than waiting until after pain is present.


Pulpal Anesthesia

Profound local anesthesia is often an elusive goal when faced with an irreversibly inflamed pulp, particularly with mandibular posterior teeth. Recent research suggests that inflammation in the pulp causes secondary changes along the entire pathway, from the peripheral site to the central nervous system. Routine local anesthesia techniques may not be sufficient to provide profound pulpal anesthesia in the presence of inflammation. Even in the absence of inflammation, an inferior alveolar nerve block is only about 60% to 75% effective.8 Lack of complete anesthesia may be acceptable for many patients undergoing routine operative procedures, but profound pulpal anesthesia is a prerequisite for root canal treatment on vital teeth.

Regardless of the inferior alveolar nerve block technique of choice (eg, standard, Gow-Gates, Akinosi), lip and tongue anesthesia does not guarantee pulpal anesthesia. Supplemental buccal and lingual infiltration may help, but is often insufficient. Intraligamentary injections can be effective if adequate back pressure is obtained. An intrapulpal injection is usually effective but is also painful and requires direct entry into the pulp prior to injection.

Interest in the use of intraosseous (IO) injections has recently increased due to the availability of easy-to-use, single-use devices. When used as a supplemental technique, IO injections provide profound anesthesia in the majority of teeth that were not already anesthetized by the standard nerve block technique.9 An IO injection with a local anesthetic containing epinephrine will almost certainly result in a transient tachycardia. In such instances, patients should be advised that it is normal to experience a temporary increase in heart rate. Use of a local anesthetic with vasoconstrictor for IO injections should be avoided in patients with significant cardiovascular disease or those taking medicines that would contraindicate the use of a vasoconstrictor. Adequate anesthesia can be obtained with an IO injection of 3% mepivicaine without vasoconstrictor,10,11 although a slightly higher dose may be required and the duration of pulpal anesthesia will be reduced to approximately 15 to 30 minutes.

Articaine (4% with 1:100,000 epinephrine) has been promoted as a more effective anesthetic, especially when used for infiltration anesthesia. Recent research comparing 4% articaine with 1:100,000 epinephrine to 2% lidocaine with 1:100,000 epinephrine for mandibular infiltration tends to support this claim,12 although it should be noted that the teeth in this study had normal (ie, noninflamed) pulps. Additionally, neither anesthetic solution, when used in an infiltration technique, was as effective as a standard inferior alveolar nerve block injection. When used for a block injection or IO injection, 4% articaine with 1:100,000 epinephrine is essentially equivalent to 2% lidocaine with 1:100,000 epinephrine.13,14 Prior to placing the rubber dam and initiating endodontic therapy, it is recommended that the tooth be tested with EndoIce or similar coolant to confirm pulpal anesthesia.

(Continued from page 1 )

Postoperative Pain Management

The most effective and predictable treatment for teeth with irreversible pulpitis is a pulpectomy and the use of NSAIDs as needed.4 For teeth with a diagnosis of acute irreversible pulpitis, the minimal treatment required to predictably diminish postoperative pain is pulpotomy, with a complete pulpectomy preferred if time permits or in the presence of apical periodontitis.15,16 Complete debridement of all canals is the emergency treatment goal for necrotic teeth.

Intracanal medications generally have no effect on postoperative pain,15 although there is limited evidence to suggest that intracanal steroids introduced into the periradicular tissues through the canal space or direct injection of an NSAID around the tooth may reduce the incidence of postoperative pain.17,18 Systemic steroids may decrease pain of inflammatory origin,19,20 although they are not routinely used in most endodontic practices. Occlusal reduction is recommended, particularly if the following conditions are present: vital pulp, percussion sensitivity, preoperative pain, and/or absence of periapical radiolucency.2 Antibiotics are not indicated for the treatment of vital teeth4 and only indicated for adjunctive management of patients with abscessed teeth and the presence of systemic complications.21  

Although most postoperative pain can be effectively managed with an NSAID only,22 occasionally the addition of a narcotic analgesic is beneficial. The combination of an NSAID and a narcotic may have a synergistic analgesic effect.23,24 A short-term (ie, 24 to 48 hours), “by the clock,” alternating combination of an NSAID and a narcotic may be considered for patients with severe pain.



Careful selection of an effective analgesic regimen may alleviate the stress and anxiety associated with endodontic therapy. This strategy, in addition to timely pulpectomy/debridement, use of a preoperative NSAID and a long-acting local anesthetic, and occlusal reduction, should result in effective pain management for almost all patients.


*Director of Postdoctoral Endodontics, University of Illinois at Chicago, Chicago, IL.




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