CONSORT Randomized Clinical Trial
Effect of Occlusal Reduction on Postoperative Pain in Teeth
with Irreversible Pulpitis and Mild Tenderness to Percussion
Masoud Parirokh, DMD, MS,* Ali Reza Rekabi, DMD, MS,† Rezvan Ashouri, DMD, MS,‡
Nouzar Nakhaee, MD,§ Paul Vincent Abbott, MDS,¶ and Hedayat Gorjestani, DDS, MS*
Abstract
Introduction: Pain management after root canal treat-
ment is a very important issue in clinical practice. The
purpose of this study was to evaluate the effect of
occlusal reduction on postoperative pain in teeth with
irreversible pulpitis and tenderness to percussion.
Methods: Fifty-four posterior vital teeth with sensitivity
to percussion requiring endodontic treatment were
included in this study. After administration of local anes-
thesia, the root canals were instrumented, and an intra-
canal calcium hydroxide dressing was placed. The
patients were randomly divided into 2 groups of 27
each. In 1 group the occlusal surface was reduced (OR
group), whereas in the other group the occlusal surface
was not modified (no occlusal reduction, NOR group).
Each patient was asked to record their postoperative
pain on a visual analogue scale with 4 categories at 6
hours, 12 hours, 18 hours, 1 day, and then daily for 6
days after this treatment. Data were analyzed by
t test, Cochran Q, c2, and Mann-Whitney tests. Results:
Forty-six patients returned the visual analogue scale
forms. There was no significant difference in postopera-
tive pain between the 2 groups (P > .05) after root canal
preparation and calcium hydroxide dressing. Conclu-
sions: Occlusal surface reduction did not provide any
further reduction in postoperative pain for teeth with
irreversible pulpitis and mild tenderness to percussion
compared with no occlusal reduction. (J Endod
2013;39:1–5)
Key Words
Calcium hydroxide, endodontic preparation, occlusal
reduction, postoperative pain, root canal treatment, 2
visit
From the *Oral and Dental Diseases Research Center,
School of Dentistry, Kerman University of Medical Sciences,
Kerman, Iran; †Endodontic Department, School of Dentistry,
Ilam University of Medical Sciences, Ilam, Iran; ‡Private Prac-
tice, Tehran, Iran; §Neuroscience Research Center, Kerman
University of Medical Sciences, Kerman, Iran; and ¶School of
Dentistry, University of Western Australia, Perth, Australia.
Address requests for reprints to Dr Masoud Parirokh, Oral
and Dental Research Center, School of Dentistry, Kerman
University of Medical Sciences, Kerman, Iran. E-mail address:
M_Parirokh@kmu.ac.ir; masoudparirokh@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.08.008
JOE — Volume 39, Number 1, January 2013
O ne of the most important aspects of endodontic practice is to control pain
during and after root canal treatment (1). Numerous investigations have been
performed to assess pain prevalence after root canal treatment (2–18). On the
basis of a recently published systematic review, the prevalence of pain after root
canal treatment has been reported to be between 3% and 58% of patients (19).
The reasons for these vast differences among the various studies could be due to
many factors, some of which may be the differences in inclusion criteria, the defi-
nition of pain after root canal treatment, the method of root canal preparation, the
number of treatment visits, the gender and age of the patients, the presence of
preoperative pain, tenderness to percussion before root canal treatment, and the
type of intracanal medication used. The many investigations of postoperative pain
have not been completely in accordance with each other regarding the influencing
factors except for the presence of preoperative pain and tenderness to percus-
sion (20).
Several strategies have been described for managing pain and discomfort after
root canal treatment. These include preoperative analgesics and corticosteroid
prescription (5, 7, 12), occlusal reduction (1, 3), and administration of long-acting
anesthesia (21–23).
It is generally accepted that there is no single factor affecting pain after root canal
treatment (14). Several factors may influence pain perception after root canal treatment
including the state of the pulp or condition of the root canal system, the presence of
a periapical radiolucency, spontaneous preoperative pain, and pain arising from the
periapical tissues (24).
Several investigations have evaluated the effects of occlusal reduction on pain and
discomfort after root canal treatment (3, 24, 25). Despite the positive conclusions of
Rosenberg et al (3) on the effect of occlusal reduction on postoperative pain, Creech
et al (24) and Jostes and Holland (25) reported no significant differences in postop-
erative pain and discomfort in patients who had received root canal treatment with or
without occlusal reduction. Hence, the results of these studies vary, and this creates
a dilemma for dentists regarding whether they should reduce occlusal contacts to
prevent pain after root canal treatment. Therefore, the purpose of the present study
was to evaluate the effect of occlusal reduction on pain after root canal treatment in
patients with irreversible pulpitis and mild tenderness to percussion without
moderate-to-severe spontaneous pain.
Materials and Methods
This study was approved by the Ethics Committee of Kerman University of Medical
Sciences in Iran (no. KA/88-01). The sample size calculation, which is based on an
error of a = 0.05 and power at 0.2, indicated that a sample size of 27 in each group
was required.
The patients included in the present study met the inclusion and exclusion criteria
described in Table 1.
The clinical diagnosis of symptomatic irreversible pulpitis was confirmed by
a response to an electric pulp test (Element Diagnostic Unit; SybronEndo, Glendora,
CA) and a prolonged exaggerated response (more than 10 seconds) with moderate-
to-severe pain to a cold test (Roeko Endo-Frost; Roeko, Langenau, Germany) after
the stimulus had been removed. The tenderness to percussion was established by using
Occlusal Reduction and Postoperative Pain 1
CONSORT Randomized Clinical Trial
TABLE 1. Inclusion and Exclusion Criteria for Participant Patients in the Present Study
Inclusion criteria
Healthy patients
Posterior maxillary or mandibular tooth
Prolonged pain to cold
Normal periapical radiographic appearance
Presence of an opposing tooth (or teeth) with normal
occlusal contact with the opposing tooth (or teeth)
Willing to continue their treatment plan until placing
a full-coverage restoration
Mild tenderness to percussion
Exclusion criteria
Patients younger than 18 years old
Presence of any systemic disorders that prevented administration of
lidocaine as the anesthetic agent
Teeth with an infected root canal system
Teeth associated with swelling
Teeth with no or moderate-to-severe tenderness to percussion
Presence of a periapical radiolucency
Pregnancy and breastfeeding
Having a tooth not suitable for restoration
Patients with moderate-to-severe spontaneous pain who needed
emergency treatment
Teeth without occlusal contact, teeth with unsupported or weak cusp
Abutments for a fixed or removable prosthesis
Mobility greater than grade 1
Teeth in which instruments had been used beyond the apical foramen
during root canal preparation
Patients who had used preoperative antibiotics or analgesics during past
24 hours
Patients with bruxism or clenching
Patients with fewer than 3 teeth on 1 side of their maxilla or mandible
Teeth with previous root canal treatment
Pocket depth greater than 5 mm
Having serious periodontal disease that rendered the tooth unsuitable for
endodontic treatment

a cotton roll between the teeth and tapping the teeth with the end of
mirror handle (3, 26).
Fifty-four patients were eligible to participate in this prospective,
randomized double-blind study. All patients were treated in the post-
graduate clinic of the Endodontic Department of Kerman Dental School
in Iran from May 2009–March 2010. Informed consent of all subjects
was obtained after the nature of the procedure and the possible discom-
forts and risks had been fully explained.
A visual analogue pain scale (VAS) was used to evaluate pain levels.
The VAS was explained to the patients, and they were instructed how to
use it. Patients were asked to complete the VAS before local anesthesia
was administered to rate their preoperative pain. The teeth were then
anesthetized by using 2 cartridges of a local anesthetic solution contain-
ing 2% lidocaine with 1:80,000 epinephrine (2% Persocaine-E; Daru-
pakhsh, Tehran, Iran).
All root canal treatment was performed by a single operator.
Biomechanical preparation of the canals was performed after establish-
ment of the working lengths by using an electronic root canal measuring
device (Root ZX; Morita Corporation, Kyoto, Japan) and confirming the
measurements with a periapical radiograph. The working length of each
root canal was set at 1 mm less than the radiographic apex. Any teeth
where the working length had been overestimated or where instruments
had inadvertently been placed beyond the working length were
excluded from the study. A 1.3% solution of sodium hypochlorite was
used as an irrigant between each instrument during root canal prepa-
ration. The root canals were instrumented initially to file size no. 15,
followed by the use of sizes 2 and 3 Gates-Glidden burs to prepare
the coronal portion of the canals. Then, HERO 642 rotary instruments
(Micro Mega, Besancon, France) were used to complete the root canal
preparation to a size 30/0.04 file used at the working length.
After the biomechanical preparation, the root canals were dressed
with calcium hydroxide paste (Golchi, Tehran, Iran), and the access
cavity was filled with a temporary restorative material (Coltosol; Asia-
chimi-Teb, Tehran, Iran). The patients were randomly divided into 2
groups of 27 each, the occlusal reduction (OR) group and the no
occlusal reduction (NOR) group, with the latter serving as a control
group. To randomize the patients, each patient was assigned a number.
The numbers in each group were written on paper, and each number
was kept in a separate sealed opaque envelope. Each patient was asked
to choose 1 of the envelopes, and on the basis of the number chosen, the
patient was assigned to 1 of the groups.
After confirming the presence of occlusal contact with articulating
paper, patients in the OR group had all occlusal contacts on the func-
tional and nonfunctional cusps as well as on the marginal ridges
reduced by 1 mm by using a diamond bur in a high-speed handpiece
with copious water spray. To ensure that the patients in the control
(NOR) group were unaware whether their teeth had been reduced,
a high-speed handpiece with copious water spray was activated inside
the patient’s mouth without contacting the occlusal surface to simulate
the procedure used in the OR group.
Patients were instructed to complete a VAS pain score to rate their
pain at 6 hours, 12 hours, 18 hours, 24 hours, 2 days, 3 days, 4 days, 5
days, and 6 days after the treatment. The following criteria were outlined
for the patients to rate their pain: 0, no pain; 1–3, mild pain; 4–6,
moderate pain; 7–9, severe pain.
The patients were instructed to use analgesics (ibuprofen 600 mg
every 6 hours [Hakim Pharmaceutical Co, Tehran, Iran]) if they felt
pain and required pain relief. The patients were also requested to
complete a second VAS form to evaluate the effect of the analgesic medi-
cation (3) if they had used any: 0, none or mild pain that does not
require analgesic medication; 1, moderate pain that was fairly well
controlled with analgesic medication and did not interfere with sleep
or daily activities; 2, unbearable pain that was not controlled with anal-
gesic medication and interfered with daily activities.
Data were analyzed by c2, Cochran Q, Mann-Whitney, and t tests.
The level of significance was set at .05.
Results
A total of 54 patients participated in the study initially, but 8 were
excluded because they did not return their VAS forms (2 in the OR group
and 6 in the NOR group). The remaining 46 patients (29 female and 17

2 Parirokh et al. JOE — Volume 39, Number 1, January 2013


male) completed the study, with the OR and NOR groups having 25 and
21 patients, respectively. The average age of the patients in the OR group
was 25.7  6.1 years, and it was 23.6  5.2 years in the NOR group. In
the OR group, 8 patients were male and 17 were female, whereas 9
patients were male and 12 were female in the NOR group. All patients
reported no to mild pain before starting the treatment. There was no
significant difference between the number of molar and premolar teeth
in the OR group (13 molars and 12 premolars) and the NOR group (14
molars and 7 premolars) (P > .05). Both groups showed no significant
differences regarding the patients’ age and gender (P > .05).
Overall, at all time intervals, 64.49% of the patients had no post-
operative pain (OR group = 52.06%, NOR group = 47.94%). The
remainder had mild pain (27.54% overall: OR group = 63.16%,
NOR group = 36.84%), moderate pain (7.25% overall: OR group =
40%, NOR group = 60%), or severe pain (0.72% overall: OR group
= 66.67%, NOR group = 33.33%) (Fig. 1). There was no significant
difference between gender and the level of postoperative pain in both
groups (P > .05).
The pain levels felt by the patients in both groups significantly
decreased after root canal treatment (P < .05; Fig. 2), but there was
no significant difference between the 2 groups.
There were no significant differences in the effects of analgesics
used by the patients in the 2 groups on the basis of the second form
(P > .05).
Discussion
The results of the present study have shown that occlusal reduction
has no significant effect on postoperative pain after root canal treatment
of teeth with irreversible pulpitis and mild tenderness to percussion.
Previous investigations on occlusal reduction have evaluated either
the patient’s comfort (25) or the amount of postoperative pain after root
canal instrumentation (3, 24), as was done in the present study. Two
previous studies (3, 24) have reported conflicting results regarding the
efficacy of occlusal reduction on postoperative pain and discomfort
after root canal treatment. The results of the present study were in
accordance with 1 of them (24), while in contrast with the other (3).
Rosenberg et al (3) reported that pulpitis, the absence of periap-
ical radiolucency, the presence of preoperative pain, and tenderness to
percussion all had significant influences on postoperative pain after
root canal treatment. For that reason, in the present study all of these
significant factors except pretreatment pain were included in the inclu-
Figure 1. The number of patients in the OR and NOR groups with different levels of pain after root canal treatment.
JOE — Volume 39, Number 1, January 2013
CONSORT Randomized Clinical Trial
sion criteria. However, the results of the present study have shown that
there was no significant effect on pain after root canal treatment in
patients having occlusal reduction compared with patients in whom
their occlusal contacts were left untreated (P > .05), despite having
the same pretreatment factors mentioned by Rosenberg et al.
Previous reports have indicated that the presence of pretreatment
pain and periapical allodynia are significant predictors for pain after
root canal treatment (3, 20, 25). In the present study, the effect of
occlusal reduction on pain after root canal treatment was evaluated
in patients with no or mild spontaneous preoperative pain but with
mild tenderness to percussion. No significant differences were
found between the 2 groups (P < .05). These findings suggest that
preoperative pain may have more effect than mild tenderness to
percussion on the efficacy of occlusal reduction. In addition, other
studies (3, 24) have reported a significant influence of preoperative pain.
Another important factor that may influence postoperative pain is
the amount of extruded apical debris after root canal treatment
(27, 28). Previous investigations on the effect of occlusal reduction
used the step-back technique for root canal preparation (3, 24). In
the present study, rotary instruments were used with the crown-down
technique. This technique has been shown to result in significantly less
apically extruded debris (29), and hence it was chosen for this study.
In general, the responses to cold and electric pulp sensibility tests
are used to determine the pulp status. In addition, bleeding in the pulp
chamber after access cavity preparation has been considered as a sign
of the pulp having an intact blood supply (30). It is generally accepted
that partial pulp necrosis in multirooted teeth may lead to either false-
negative or false-positive responses to pulp sensibility tests. Hence,
visual inspection and the presence of bleeding after access cavity prep-
aration have been used as the gold standard in recognizing the pulp
status (31, 32). This approach was used in the present study, and
pulp vitality was only confirmed from the moment of pulp exposure
when bleeding was observed. Any patients who did not have bleeding
from the pulp at this stage were not included in the study.
Rosenberg et al (3) evaluated the effect of occlusal reduction on
posterior teeth. In the present study, only posterior teeth (both molars
and premolars) were included to be able to compare the results with
that study.
It is considered acceptable to reduce the occlusal surface of a tooth
when 1 or more walls of the cavity have undermined enamel. It is also
acceptable when the dentist has ensured that the patient can afford and
is willing to continue treatment by having full coverage over the occlusal
Occlusal Reduction and Postoperative Pain 3
CONSORT Randomized Clinical Trial
Figure 2. The number of patients with moderate-to-severe pain in OR and
NOR groups.
surface. It has been recommended to use full coverage over occlusal
surfaces of posterior teeth after root canal treatment (33–35).
However, if the patient does not proceed with full-coverage restoration
of the tooth after root canal treatment and the dentist had reduced the
occlusal surface to prevent possible postoperative pain, the tooth would
then have no function. In 2 surveys conducted among American board-
certified endodontists, the use of occlusal adjustment was evaluated
(36, 37). In the 1974–1975 survey, respondents performed occlusal
adjustment for pulpitis cases with or without apical periodontitis 80%
and 48.8% of the time, respectively (36). However, in the 1988 survey,
the percentages were 73.2% and 40.1%, respectively (37). An investi-
gation of the types of restorations done after root canal treatment by
using an electronic data base of patient records showed that only
27% of endodontically-treated teeth had received full occlusal coverage
(35). Therefore, clinicians and patients should be aware of the possible
disadvantages associated with occlusal reduction.
There are very few reports regarding the efficacy of calcium
hydroxide in reducing postoperative pain when used as a root canal
medicament. Some studies have reported favorable results (38, 39),
whereas others have reported no significant difference on
postoperative pain with or without dressing with the medication
(40–42). The results of these studies vary because different conditions
of the pulp, root canal, and periapical tissues have been included
rather than limiting the included cases to a specific diagnosis. Some of
these studies have also compared different medicaments (42). In the
present study, both groups had calcium hydroxide placed in the canals,
but this is in contrast to previous investigations of the effect of occlusal
reduction where the root canals were left empty (3, 24).
The results of the present study suggest that the presence of
moderate-to-severe preoperative pain may be a stronger predictor of
postoperative pain than tenderness to percussion, which is consistent
with the findings of O’Keefe (43).
In the present study teeth that may have had excess or greater than
normal occlusal contact were excluded. Such teeth were defined as
those having no neighboring tooth and when there were fewer than 3
posterior teeth in the mouth.
In conclusion, occlusal reduction in teeth with irreversible pulpitis
and mild tenderness to percussion had no significant influence on post-
operative pain after root canal preparation.
Acknowledgments
The authors deny any conflicts of interest related to this study.
4 Parirokh et al.
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