Professional Documents
Culture Documents
Abstract
Introduction: Patients without a dentist or access to
care may present to emergency rooms with pain. They
are often prescribed medications until they can be
S ymptomatic teeth with a pulpal diagnosis of necrosis are frequently treated in a
specialty endodontic practice (1–5). Usually, accessing the tooth and performing
endodontic debridement are completed at the initial emergency visit. However,
treated. There are no studies to show if emergency end- patients without a dentist or access to immediate dental care may present to
odontic debridement is better than giving medications hospital emergency rooms with dental pain and are often prescribed pain
during this symptomatic period. The purpose of this pro- medication and antibiotics and referred to a dentist for evaluation and treatment
spective, randomized study was to compare debride- (6). According to the National Hospital Ambulatory Medical Care Survey, dental
ment versus no debridement on postoperative pain in emergency room visits in the United States increased by 1 million from 2000 to
emergency patients with symptomatic teeth, a pulpal 2010 (7). A community dental health coordinator stated that she sees patients daily
diagnosis of necrosis, and a periapical radiolucency. who have waited too long for dental treatment. ‘‘Often, they’ve visited the emergency
Methods: Ninety-five patients presenting with moder- room and received antibiotics as a temporary treatment but haven’t followed up with
ate to severe pain were analyzed. The patients were a dentist to completely resolve their problem’’ (7). A retrospective analysis of pa-
randomly divided into 2 groups: group 1 received anes- tients admitted to the emergency room with a diagnosis of periapical abscess
thesia and endodontic debridement, and group 2 showed that over 9 years there were 61,439 hospitalizations because of periapical
received anesthesia but no debridement. At the end of abscess in the United States (8). In addition, the number of hospitalizations
the appointment, all patients were given ibuprofen/acet- increased 41% from 2000 to 2008 (8). A study assessed the prevalence and costs
aminophen. If needed, they could receive an escape associated with emergency department visits in 2006 and found there were 403,149
medication. Patients received a 5-day diary to record emergency department visits in a year associated with pulpal and periapical disease
their pain levels and medication taken. Success was totaling $163,692,957 in hospital charges (9).
defined as no or mild postoperative pain and no use of Dental emergency room visits were evaluated and described from 1997 to 2000 by
escape medication. Success data were analyzed using Lewis et al (6). There were 2.95 million dental emergency department visits in total, and
a logistic regression. Results: Both groups had a at least 1 prescription was given in more than 80% of visits; antibiotics were prescribed
decrease in postoperative pain and medication use in 49% of visits, whereas 72% of patients received analgesics (38% received a narcotic
over the 5 days. The debridement group had a signifi- prescription). The dental emergency department visits were more likely to occur on the
cantly higher success rate than the no debridement weekend when many dental offices were not open (6).
group. There was no significant difference between the Although many emergency room physicians recommend more definitive
2 groups with respect to escape drug use. Conclusions: follow-up care, it is not known how many of these patients follow through with
Patients receiving debridement or no debridement had a this recommendation. Dental-related emergency room visits from 5 major hospital
decrease in postoperative pain over the 5 days. Debride- systems in Minneapolis over 1 year showed that over 10,000 visits were related to
ment resulted in a statistically higher success rate, but dental problems (10). Of these 10,000 visits, 2,499 were second or additional
there was no significant difference in the need for repeat visits for a dental problem. Therefore, about 20% of the dental-related
escape medication. (J Endod 2016;42:378–382) emergency room visits were repeat visits. A major concern with the treatment
of dental problems in a hospital setting is the lack of follow-up and definitive
Key Words dental treatment (10–12).
Endodontic debridement, endodontic pain, pulpal Although it is known that patients are commonly prescribed antibiotics and pain
necrosis, symptomatic endodontic patients medication for dental pain in the emergency room, it is not known what happens
to these patients once they leave the hospital setting (6). If they do not seek
immediate dental treatment, what is the amount and duration of postoperative
From the *Practice Limited to Endodontics, San Antonio, pain they experience?
Texas; and Divisions of †Endodontics and ‡Biosciences, The There are currently no studies to show if initial endodontic debridement is
Ohio State University, Columbus, Ohio. better than just placing the emergency patient on medications for pain relief during
Address requests for reprints to Dr Melissa Drum, The Ohio this symptomatic period. The purpose of this prospective randomized study was to
State University, Postle Hall, 305 West 12th Avenue, Columbus,
OH 43210. E-mail address: drum.13@osu.edu
compare the effects of endodontic debridement versus no endodontic debridement
0099-2399/$ - see front matter on postoperative pain in emergency patients with symptomatic teeth, a pulpal diagnosis
Copyright ª 2016 American Association of Endodontists. of necrosis, and a periapical radiolucency.
http://dx.doi.org/10.1016/j.joen.2015.12.001
JOE — Volume 42, Number 3, March 2016 Symptomatic Teeth with Pulpal Necrosis 379
Clinical Research
TABLE 3. Percentages and Discomfort Ratings of Postoperative Pain for the Debridement and No Debridement Groups (excluding patients who took narcotics)
Group None Mild Moderate Severe Median P value
Day 0*
Debridement 3% (1/37) 35% (13/37) 54% (20/37) 8% (3/37) 58.0 .8587
No debridement 9% (4/42) 38% (16/42) 38% (16/42) 14% (6/42) 57.5
Day 1
Debridement 8% (3/36) 42% (15/36) 47% (17/36) 3% (1/36) 52.0 .0982
No debridement 7% (3/43) 26% (11/43) 60% (26/43) 7% (3/43) 59.0
Day 2
Debridement 4% (2/45) 49% (22/45) 42% (19/45) 4% (2/45) 36.0 .0975
No debridement 8% (4/47) 32% (15/47) 49% (23/47) 11% (5/47) 58.0
Day 3
Debridement 27% (12/44) 39% (17/44) 32% (14/44) 2% (1/44) 22.0 .0496
No debridement 15% (7/47) 40% (19/47) 38% (18/47) 6% (3/47) 46.0
Day 4
Debridement 23% (10/44) 50% (22/44) 27% (12/44) 0% (0/44) 20.5 .0170
No debridement 15% (7/47) 36% (17/47) 42% (20/47) 6% (3/47) 45.5
Day 5
Debridement 39% (17/44) 39% (17/44) 23% (10/44) 0% (0/44) 3.0 .0060
No debridement 19% (8/43) 44% (19/43) 30% (13/43) 7% (3/43) 38.0
*Night of treatment when local anesthesia wore off.
availability. The patient was instructed to stop taking the ibuprofen and type were analyzed using the Fisher exact test. Corah anxiety ratings
acetaminophen once starting the escape medication to avoid exceeding were assessed using the Mann-Whitney-Wilcoxon test.
recommended drug dosing. The patient was seen emergently in the Between-group differences in success were evaluated using a
clinic if the need arose. repeated measures logistic regression with group, day, and sex as the
Patients received a diary for the day of the appointment and 5 days independent variables. A mixed model analysis of variance with postop-
postoperatively to record any pain they were having and the amount of erative day, patient sex, and treatment group as the independent vari-
pain (ibuprofen/acetaminophen combination or escape) medication ables was used to evaluate total analgesic use. Tooth type and jaw
taken. Patients recorded the type and number of pain medications taken were included as random variables. Post hoc testing was performed us-
during the time period between the completion of the endodontic pro- ing the Tukey-Kramer procedure. Because the postoperative pain values
cedure and before going to bed the night of the appointment after the were not normally distributed, they were analyzed nonparametrically
local anesthesia had worn off. For the next 5 days, patients recorded using multiple randomization tests with the P values adjusted using
pain on the Heft-Parker VAS and the type and number of pain medica- the step-down Bonferroni method of Holm. Comparisons were consid-
tions taken each day. Patients were asked to return all unused medica- ered significant at P < .05. For VAS pain scores, assuming a standard
tions upon completion of the study to verify diary input. The patients deviation of 50.3 (5), a difference of 30 mm could be detected
assigned to the no debridement group were scheduled for endodontic with a power of 0.80 with 45 patients per group.
treatment 5 days later or at their earliest convenience. Success
was defined as none or mild postoperative pain and no use of narcotic
medications. Overall success was calculated for the debridement and no Results
debridement groups. A total of 108 subjects were enrolled in this study. Thirteen sub-
The data from this study were statistically analyzed. Comparisons jects were disqualified for the following reasons: 1 because of a fracture
between the debridement and no debridement groups for age and initial
pain ratings were made using the randomization test. Comparisons in TABLE 4. Mean Number of the Combination Medications Taken (excludes
sex and jaw were analyzed via chi-square tests. Differences in tooth patients who took narcotics)
Number of Mean number
Group patients tablets P value
Day 0*
Debridement 37 4.8 2.7 1.0000
Nondebridement 43 4.4 3.1
Day 1
Debridement 37 6.3 3.8 .7874
Nondebridement 43 7.8 3.9
Day 2
Debridement 37 4.9 3.8 .4742
Nondebridement 43 6.8 4.0
Day 3
Debridement 37 3.6 3.6 .1996
Nondebridement 43 5.9 4.1
Day 4
Debridement 37 2.9 4.0 .6703
Nondebridement 43 4.6 3.6
Day 5
Debridement 37 2.2 3.9 .4562
Nondebridement 40 4.2 3.7
Figure 1. Postoperative pain by group and day. *Night of treatment when local anesthesia wore off.
detected upon endodontic access, 11 for not returning postoperative The patients in the no debridement group did not get worse over
surveys, and 1 for not disclosing the use of Percocet daily for chronic the 5 days, indicating that analgesics may help these symptomatic pa-
back pain. Ultimately, 10 patients were disqualified from the debride- tients presenting with a necrotic pulp and associated periapical radio-
ment group, and 3 patients were disqualified from the no debridement lucency. The use of antibiotics would not be expected to help because
group. Therefore, the total number of subjects analyzed was 46 in the the use of antibiotics does not result in a significant improvement in the
debridement group and 49 in the no debridement group. resolution of symptoms of symptomatic teeth with pulpal necrosis or
Table 1 shows the preoperative variables. There were no statisti- acute apical abscesses (3, 15). If the patient is immunocompromised
cally significant differences between the 2 groups with regard to age, or has significant medical conditions, perhaps complete debridement
sex, presenting pain, Corah anxiety ratings, tooth location, or jaw. would be indicated versus no debridement.
Table 2 shows the regression summary for treatment success. Although pain was reduced from presenting pain levels, mod-
There were significant effects for treatment group (odds ratio = erate to severe pain levels were still reported by 52%–62% of the
1.519; 95% confidence interval, 1.055–2.185 for debridement vs no patients the night of the treatment and 50%–67% of the patients
debridement), sex (odds ratio = 0.548; 95% confidence interval, on day 1 (Table 3). Most medication usage was in the first several
0.380–0.788 for females vs males), and day. All interaction effects days and decreased over the 5 days paralleling the decreasing pain
were not significant (P > .259). (Table 3, Fig. 2). The decrease in tooth pain over the 5 days is most
Table 3 shows pain by day for the debridement and no debridement likely attributable to the natural course of the disease process for the
groups. Moderate to severe pain was experienced by 52%–62% of the clinical condition of a symptomatic tooth with a necrotic pulp and an
patients the night of the treatment and 50%–67% of the patients on associated periapical radiolucency. Other authors (1–5) showed that
day 1, with the pain ratings decreasing over the next 4 days. Significantly the majority of patients started to improve regardless of drug or
lower pain values were noted for the debridement group for days 3 active treatment protocols on the third postoperative day. Our
through 5. Figure 1 shows the postoperative pain ratings over the 5 days. results confirm these observations. Patients improved even without
Table 4 and Figure 2 show the mean number of combination emergency debridement.
ibuprofen/acetaminophen tablets taken by day for the debridement Twenty percent (9/46) of patients in the debridement group
and no debridement groups. The highest number of medication use and 12% (6 of 49) in the no debridement group took escape med-
was on day 1, with decreasing use over the next 4 days. Twenty percent ications with no significant (P = .3218) difference between the
(9/46) of patients in the debridement group and 12% (6 of 49) in the groups (Fig. 3). Wells et al (5) found 20% of patients used escape
no debridement group took escape medications with no significant medication (Vicodin) when the combination of ibuprofen and acet-
(P = .3218) difference between the groups (Fig. 3). aminophen was ineffective for pain control in symptomatic patients
with a necrotic pulp and an associated periapical radiolucency who
were experiencing moderate to severe preoperative pain. There-
Discussion fore, the combination of ibuprofen and acetaminophen would
Differences in the preoperative variables would be minimized not be completely effective for controlling postoperative pain in
because no statistically significant differences were shown between
groups (Table 1). The presenting initial moderate pain level
(Table 1) is representative of emergency patients with symptomatic
teeth, a pulpal diagnosis of necrosis, and a periapical radiolucency as
shown by Wells et al (5). Because most subjects in both groups reported
low to moderate Corah scores (Table 1), anxiety may not have played a
large role in influencing the pain associated with debridement or no
debridement. The influence of tooth location was minimized because
the teeth were evenly distributed (Table 1).
The debridement group had a significantly higher odds of success
(no to mild pain and no narcotic use) than the no debridement group.
Therefore, the best clinical outcome would be to completely debride the
tooth at the emergency visit. Endodontists would be likely to perform
complete debridement because of their advanced training and experi-
ence. However, inexperienced operators may not be able to perform
complete debridement at the emergency visit. Figure 3. Escape drug use.
JOE — Volume 42, Number 3, March 2016 Symptomatic Teeth with Pulpal Necrosis 381
Clinical Research
these patients. However, even with no debridement, most patients 4. Nusstein J, Reader A, Beck M. Effect of drainage upon access on postoperative end-
did not require escape medication. Symptom improvement without odontic pain and swelling in symptomatic necrotic teeth. J Endod 2002;28:584–8.
5. Wells LK, Drum M, Nusstein J, et al. Efficacy of ibuprofen and ibuprofen/acetamin-
treatment and lack of narcotic use may be important in certain ophen on postoperative pain in symptomatic patients with a pulpal diagnosis of ne-
clinical scenarios. crosis. J Endod 2011;37:1608–12.
We concluded patients receiving debridement or no debridement 6. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a na-
had a decrease in postoperative pain and medication use over the tional perspective. Ann Emerg Med 2003;42:93–9.
5 days. Complete endodontic debridement resulted in a statistically 7. Soderlund K. ERs seeing increase of people visiting with dental problems. Avail-
able at: http://www.alliance.ada.org/news/8750.aspx. Accessed April 10, 2014.
higher success rate when compared with no endodontic debridement, 8. Shah AC, Leong KK, Lee MK, Allareddy V. Outcomes of hospitalizations attributed to
but there was no significant difference in the need for escape (narcotic) periapical abscess from 2000 to 2008: a longitudinal trend analysis. J Endod 2013;
medication between the 2 groups. 39:1104–10.
9. Nalliah RP, Allareddy V, Elangovan S, et al. Hospital emergency department visits
Acknowledgments attributed to pulpal and periapical disease in the united states in 2006. J Endod
2011;37:6–9.
The authors deny any conflicts of interest related to this study. 10. Davis E, Deinard A, Maiga E. Doctor, my tooth hurts: the costs of incomplete dental
care in the emergency room. J Public Health Dent 2010;70:205–10.
11. Allareddy V, Rampa S, Lee MK, et al. Hospital-based emergency department visits
References involving dental conditions. J Am Dent Assoc 2014;145:331–7.
1. Houck V, Reader A, Beck M, et al. Effect of trephination on postoperative pain and 12. Lewis CW, McKinney CM, Lee HH, et al. Visits to US emergency departments by 20- to
swelling in symptomatic necrotic teeth. Oral Surg Oral Med Oral Pathol Oral Radiol 29-year-olds with toothache during 2001-2010. J Am Dent Assoc 2015;146:295–302.
Endod 2000;90:507–13. 13. Heft MW, Parker SR. An experimental basis for revising the graphic rating system for
2. Nist E, Reader A, Beck M, Weaver J. An evaluation of apical trephination on pain. Pain 1984;19:153–61.
postoperative endodontic pain in symptomatic necrotic teeth. J Endod 2001;27: 14. Corah NL. Development of a dental anxiety scale. J Dent Res 1969;48:596.
415–20. 15. Fouad AF, Rivera EM, Walton RE. Penicillin as a supplement in resolving the
3. Henry M, Reader A, Beck M, Gallatin E. Effect of penicillin on postoperative pain and localized acute apical abscess. Oral Surg Oral Med Oral Pathol 1996;81:
swelling in symptomatic, necrotic teeth. J Endod 2001;27:117–23. 590–5.