CONSORT Randomized Clinical Trial
Randomized Clinical Trial of Intraosseous
Methylprednisolone Injection for Acute Pulpitis Pain
Khaly Bane, DDS, PhD,* Emmanuel Charpentier, DDS, Msc,†‡ François Bronnec, DDS,‡§
Vianney Descroix, DDS, PhD,‡§ Fatou Gaye-N’diaye, DDS, PhD,*
Abdoul Wahabe Kane, DDS, PhD,* Rafael Toledo, DDS,‡ Pierre Machtou, DDS, PhD,‡§
and Jean Az
erad, DDS, PhD‡§
Abstract
Introduction: The present study reports the results of a
randomized clinical trial comparing local intraosseous
methylprednisolone injection and emergency pulpotomy
in the management of acute pulpitis on efficacy, safety,
and efficiency end points. Methods: After providing
prior informed written consent, 94 patients consulting
for acute irreversible pulpitis pain at university-
affiliated teaching hospital dental clinics in Dakar,
Senegal were randomly assigned to either the methyl-
prednisolone treatment group (n = 47) or the pulpotomy
treatment group (n = 47). Patients were followed up at
1 week and assessed 6 months later to evaluate the
therapeutic outcome of their treatment. Results: At
day 7 the patients in the methylprednisolone group re-
ported less intense spontaneous and percussion pain
in the day 0–day 7 period than the patients in the pul-
potomy group. Methylprednisolone treatment took
approximately 7 minutes (4.6–9.3) less to accomplish
than pulpotomy (or about half the time). No difference
in the therapeutic outcome was found between the 2
treatment groups at 6 months (all credible intervals
span 0). Conclusions: This study establishes that
methylprednisolone injection for acute pulpitis is
relieved by a minimally invasive pharmacologic
approach more effectively than by the reference pulpot-
omy and conserves scarce dental resources (ie, end-
odontic equipment and supplies, dental surgeon’s
time). (J Endod 2016;42:2–7)
Key Words
Emergency treatment, endodontics, pain management,
pulpitis
From the *Service d’Odontologie Conservatrice et Endo-
dontie, D
epartement d’Odontologie, Facult
e de M
edecine,
Pharmacie et d’Odonto-Stomatologie, Universit
e Cheikh Anta
Diop de Dakar, Dakar, S
en
egal; †Secr
etariat Scientifique du CE-
DIT-PIVT, Assistance Publique-H^opitaux de Paris; ‡Service
d’Odontologie, Groupe Hospitalier Piti
e-Salp^etriere; and §UFR
d’Odontologie, Universit
e Denis Diderot, Paris, France.
Address requests for reprints to Dr Emmanuel Charpentier,
Secr
etariat Scientifique du CEDIT, 3, avenue Victoria,
F-75186 Paris CEDEX 04, France. E-mail address: emmanuel.
charpentier@sap.aphp.fr
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.09.003
2 Bane et al.
A lthough treatment of acute pulpitis is now well-managed, emergency manage-
ment of this usually painful condition may constitute an unanticipated and sig-
nificant workload that disrupts the normal workflow in a dental office or clinic.
Emergency pulpotomy is widely recognized as either the reference procedure for
managing of this type of emergency (1) or as an efficient alternative to impractical
total pulpal extirpation (2).
However, the superiority of these 2 approaches appears to be based on insufficient
evidence. Whereas some reference studies have compared various therapeutic pulpot-
omy modalities, we were unable to find a randomized comparison of this procedure
with another emergency protocol in the literature. Furthermore, pulpotomy requires
the collaboration of a dentist who is competent in endodontics as well as significant
technical setup and sufficient time.
Previous studies have highlighted the possibility of obtaining mid-term (a few
weeks) pain relief by using a pharmacologic approach, thereby allowing planned
endodontic management of the causal disease. Among these studies, a double-
blinded, randomized trial (versus a physiological serum placebo) demonstrated
the anti-inflammatory effects of intraosseous glucocortocoid injection and suggested
that clinically satisfactory pain relief could be obtained by using a pharmacologic
approach (3). However, the cohort studied in this report was too small to assess
the safety of this procedure. Furthermore, the control used in this study was a pla-
cebo, which did not permit evidence-based comparison of intraosseous glucocorti-
coid injection with the emergency pulpotomy reference procedure. Therefore, we
designed a randomized clinical trial that was able to determine whether this phar-
macologic approach was as effective as emergency pulpotomy in the management of
acute pulpitis as well as assessing whether it was safe to use. Our study did not aim
to explain the physiological and pharmacologic mechanism(s) of the use of
methylprednisolone injection for acute pulpitis pain.
Materials and Methods
All adult patients consulting in the emergency department of 3 dental clinics at the
Dental Schools of the University of Dakar (Senegal) who were complaining of pain that
was due to acute irreversible pulpitis of a permanent premolar or molar during the
study period (from April through September 2009) were assessed for inclusion criteria
in a 1:1 parallel-group randomized clinical trial.
Population
Inclusion and exclusion criteria were applied to recruit patients for the trial who
presented irreversible pulpitis as specified in Supplemental Materials S1, section 1. All
patients enrolled in the study were considered to be in acceptable periodontal, regional,
and general health to the exclusion of patients presenting local, regional, or general
pathology that would counterindicate either pulpotomy or prednisolone injection. In
particular, patients presenting pulpitis of possible non-carious origin and those of ques-
tionable local periodontal health were excluded. Patients unable to understand the writ-
ten protocol or unwilling to provide written consent were also excluded from the study.
JOE — Volume 42, Number 1, January 2016

Patient Selection and Information
The trial protocol was presented orally and in writing to sequen-
tially consulting patients in 3 Dakar University–affiliated dental clinics
who had acute irreversible pulpitis of carious origin. Those who ex-
pressed interest in participating in the trial were screened according
to the trial inclusion and exclusion criteria. Informed prior written con-
sent was obtained from all patients enrolled in the study.
Treatment Allocation
A randomization list was established by a statistician who prepared
sequentially labeled opaque numbered envelopes containing the treat-
ment group assignment for each patient to permit a posteriori alloca-
tion checking. The envelopes were available to investigators at all times,
who were blinded to the allocation table. Each newly enrolled patient
was assigned to a treatment group by the investigator on opening the
randomization envelope bearing the patient’s inclusion number.
Initial (Emergency) Treatment and Discharge
Patients were randomly assigned to either the reference initial
treatment group or the experimental initial treatment group, as
described above. On discharge after initial treatment, patients were pre-
scribed a standard analgesic prescription (systematic: ibuprofen
400 mg 3 times a day for 7 days; in case of need, acetaminophen
500 mg + codeine 30 mg as needed, maximum 6/day), a data-
collection form for recording pain experienced during the 7-day waiting
period before definitive treatment, and instructions to return to where
they were treated in case of unexpected events.
Reference Emergency Treatment (Pulpotomy). Pulpotomy
was performed according to a standard protocol, as described by Tron-
stad (1). The tooth was anesthetized (periapical local anesthesia or
inferior alveolar nerve block, with either intraligament or intraseptal
infiltration [decided by the operator]), isolated (rubber dam), and
then disinfected with an antiseptic solution after pre-endontic restora-
tion if required. All carious dentin was removed, and an access cavity
was achieved to allow total pulp chamber tissue removal (excavator,
long-neck round bur). After hemostasis (compression, sodium hypo-
chlorite), a dry sterile cotton pellet was placed in the pulpal cavity,
which was then hermetically sealed with temporary cement, followed
by occlusal correction.
Experimental Emergency Treatment (Intraosseous
Methylprednisolone Injection). The technique used for meth-
ylprednisolone injection was described by Gallatin et al (3). After anes-
thesia (intraligament and intraseptal infiltration was excluded in the
experimental treatment group protocol), the tooth and adjacent gingiva
were disinfected with an antiseptic, and an injection point was chosen
(in attached gingiva, around 5 mm below the cervical line away from
dental roots.) The cortical bone was then perforated by using a
single-use intraosseous anesthesia device (X-tip; Dentsply Maillefer In-
struments, Ballaigues, Switzerland), including a drill (run at 10,000
rpm) and a guide sleeve, which was left in place for injection of the
drug. Methylprednisolone (Depo-Medrol, Pfizer, New York, NY;
40 mg/mL) was then slowly injected (1 mL in 1–2 minutes) by using
a 27-gauge needle and a dental anesthetic syringe. After removal of
the drill-perforator (and hemostasis if necessary), patients were pre-
scribed the same standard analgesic and issued the same documents
and instructions as patients in the control group.
Definitive Treatment and Follow-up
After the 7-day waiting period after initial treatment, patients
received endodontic treatment and restoration of the affected tooth.
JOE — Volume 42, Number 1, January 2016
CONSORT Randomized Clinical Trial
Six months after definitive treatment, patients were recalled for mid-
term assessment of the state of the affected tooth.
Data Collection
Data collection is described in Supplemental Materials S1, section
2 (available online at www.jendodon.com). Spontaneous and percuss-
sion pain intensity was assessed on the 4-point oral scale already used
by Gallatin et al (3): ‘‘Zero indicated no pain. One indicated mild pain,
pain that was recognizable but not discomforting. Two indicated mod-
erate pain, pain that was discomforting but bearable. Three indicated
severe pain, pain that caused considerable discom fort and was difficult
to bear.’’ These data were analyzed as an ordinal variable.
Power and Sample Size
The study was planned as a non-inferiority sequential trial on the
basis of extrapolation of the results by Gallatin et al (3). The objective
was to be able to detect non-inferiority with a margin representing a
pain score (sum of pain intensities [SPI] during the day 0–day 7 inter-
val) in one group double that of the pain score in the other group, with
first-type and second-type error rates of 0.05 and 0.8, respectively, and
5 interim analyses. The latter requirement raised the necessary sample
size to 47 patients per treatment group; the expectation of the number of
subjects effectively then included was 31 subjects. This sample size also
allowed for an initial safety assessment; an event with probability of 0.05
had to be observed at least once in each treatment group, with proba-
bility of 0.91.
Statistical Analysis
The data were analyzed by building a bayesian model along the
lines suggested by Spiegelhalter et al (4). This model is discussed
and described in Supplementary Materials S1, sections 3 and 4 (avail-
able online at www.jendodon.com).
Qualitative variables were analyzed by logistic regression, quanti-
tative variables by regression (generalization of Student t test); the or-
dered (non-quantitative) variables (ie, the pain during the waiting
period and the summarizing scores SPI and sum of pain intensity differ-
ences [SPID], main judgement criteria) were analyzed by polychoric
ordered logistic regression.
The results are reported as raw numbers (qualitative and ordered
variables) or mean and standard deviation (quantitative variables); the
group comparison results are expressed by the median and the 95%
highest posterior density credible interval of the regression coefficients
representing the effect of treatment in the model (which coincides with
mean differences for quantitative variables).
Ethical Considerations
The experimental protocol was approved by the Scientific Commit-
tee of Dakar University (Dakar, Senegal), serving as an Institutional Re-
view Board. Patients were informed that even after having given their
initial consent, they were free to withdraw from the study at any time
with no effect on their clinical management.
Results
During the study period (from April through September 2009), 94
patients in 3 Dakar University–affiliated dental centers were included in
the trial and treated by the same operator. Logistical problems pre-
cluded interim analyses, and the trial proceeded to its maximal planned
size. One minor protocol deviation was recorded; a patient in the
methylprednisolone group received a supplemental periapical infiltra-
tion as well as the mandibular nerve block necessary for treatment of his
Methylprednisolone in Acute Pulpitis 3
CONSORT Randomized Clinical Trial

Figure 1. Patient flow in the study. D7, day 7.

tooth. Therefore, the intention-to-treat analysis coincides with the
effective-treatment analysis. Patient flow is illustrated in Figure 1.
There were some minor imbalances between the groups. Pre-
intervention intergroup differences are tabulated in Supplemental
Table S1 (available online at www.jendodon.com) (patient character-
istics) and Table 1 (teeth characteristics) and illustrated in
Supplemental Figure S1 (available online at www.jendodon.com).
Pre-treatment pain duration was shorter and the percussion pain score
was higher in the methylprednisolone (experimental) group (their 95%
credible intervals do not contain 0). The other patients’ characteristics
were well-matched between the groups.
Early treatment results are tabulated in Table 2 and illustrated in
Supplemental Figure S2 (available online at www.jendodon.com). The
time required to accomplish methylprednisolone treatment was about
7.3 minutes (ie, 7.0 minutes less than pulpotomy). Immediately after
treatment, both spontaneous pain and percussion pain were less intense
in the methylprednisolone experimental (experimental) group.
On day 4, one patient in the methylprednisolone group presented
with complaints of unbearable pain. After pulpotomy, the patient
recovered uneventfully and was followed up at 7 days and 6 months.
Her pain records were imputed maximal values for days 1–4 and were
model-imputed afterwards. One patient in the experimental group re-
ported headache and hot flashes at day 7. She was referred to a cardi-
ologist, who was unable to diagnose the reported problem; therefore,
one cannot confirm or deny a causal link to the experimental
treatment.
Ten patients were lost to follow-up. Five patients presented at day 7
with unfilled or illegible pain records; these values were model-
imputed.
During the 7-day waiting period (raw results in Table 3, analysis in
Supplemental Table S2 (available online at www.jendodon.com), illus-
trated in Fig. 2), less percussion pain was reported by patients in the
experimental group in which spontaneous pain tended to be less
intense, but the 95% credible interval for spontaneous pain (barely)
contains 0. It should be noted that the summary indices SPI, which
do not account for intrapatient correlations, were sharply smaller in
the experimental group; conversely, the SPID indices (indices for relief
of the initial pain) were sharply greater in the experimental group. One

TABLE 1. Treated Teeth Characteristics

Randomization to
Variable Prednisolone Pulpotomy Group effect 95% credible interval Pseudo p
Molar 38 (81%) 42 (89%) 0.804 ( 2.090, 0.421) .093
Mandibular tooth 26 (55%) 32 (68%) 0.581 ( 1.414, 0.303) .095
Fast caries 3 (6%) 5 (11%) 0.598 ( 2.305, 0.918) .219
Narrow periodontal probing 1 (2%) 0 (0%) (1 NA) 0.034 ( 0.779, 0.836) .467
Rx: Dentinogenic attempt failure 2 (4%) 1 (2%) 0.834 ( 1.805, 4.217) .260
Rx: Pulpal-oral communication 3 (6%) 2 (4%) 0.743 ( 1.324, 2.886) .229
Cold test 46 (98%) 47 (100%) 0.078 ( 0.916, 0.702) .424
Heat test 42 (89%) 45 (96%) (1 NA) 1.873 ( 4.972, 0.366) .042
Percussion test 43 (91%) (1 NA) 44 (94%) 0.031 ( 1.799, 1.765) .486
Intermittent pain 46 (98%) 47 (100%) 0.085 ( 0.902, 0.734) .419
Irradiating pain 37 (79%) 40 (85%) 0.787 ( 1.982, 0.417) .093
Spontaneous pain 46 (98%) 47 (100%) 0.089 ( 0.876, 0.768) .415
Initial pain duration (days)
1 13 (28%) 5 (11%)
2 4 (9%) 17 (36%)
3 13 (28%) 9 (19%)
4 16 (34%) 15 (32%)
NA 1 (2%) 1 (2%) 1.258 ( 2.228, 0.237) .003
Initial spontaneous pain intensity
2 11 (23%) 15 (32%)
3 36 (77%) 32 (68%) 0.826 ( 3.426, 4.524) .341
Initial percussion pain intensity
0 2 (4%) 2 (4%)
1 1 (2%) 1 (2%)
2 17 (36%) 21 (45%)
NA, not available; Pseudo p, probability of a coefficient having a sign inverse of its median; Rx, radiologic sign.
Pain intensity measurement is described in text.

4 Bane et al. JOE — Volume 42, Number 1, January 2016

 CONSORT Randomized Clinical Trial
TABLE 2. Immediate and Short-term Results of the Treatments
Randomization to
Group
Variable Prednisolone Pulpotomy effect 95% credible interval Pseudo p
Treatment work time (min) 7.29  2.74 14.15  5.89 7.016 ( 9.360, 4.556) .000
Postoperative spontaneous pain intensity
0 45 (96%) 36 (77%)
1 0 (0%) 9 (19%)
2 0 (0%) 2 (4%)
NA 2 (4%) 0 (0%) 1.695 ( 3.192, 0.338) .007
Postoperative percussion pain intensity
0 44 (94%) 26 (55%)
1 3 (6%) 14 (30%)
2 0 (0%) 7 (15%) 13.450 ( 18.544, 9.019) .000
Overall treatment effect on spontaneous pain during the waiting period 1.939 ( 4.358, 0.437) .048
Overall treatment effect on percussion pain during the waiting period 6.168 ( 8.252, 4.040) <.43.10 4
Spontaneous pain SPI Derived from previous estimation 1.787 ( 2.362, 1.213) <1.43.10 4
Percussion pain SPI Derived from previous estimation 4.468 ( 5.064, 3.809) <1.43.10 4
Spontaneous pain SPID Derived from previous estimation 2.362 (1.447, 3.213) <1.43.10 4
Percussion pain SPID Derived from previous estimation 7.128 (6.149, 8.000) <1.43.10 4
Presence at follow-up 41 (87%) 43 (91%) 0.653 ( 1.853, 3.376) .302
Spontaneous pain at day 7
0 38 (93%) 28 (65%)
1 3 (7%) 14 (33%)
3 0 (0%) 1 (2%)
NA 6 (15%) 4 (9%) 2.087 ( 4.148, 0.233) .017
Percussion pain at day 7
0 34 (83%) 17 (40%)
1 7 (17%) 22 (51%)
2 0 (0%) 3 (7%)
3 0 (0%) 1 (2%)
4
NA 6 (15%) 4 (9%) 3.373 ( 4.901, 1.825) <1.43.10
Wide periodontal probing at 1 (2%) (6 NA) 0 (0%) (4 NA) 0.192 ( 0.681, 1.041) .334
day 7

NA, not available; Pseudo p, probability of a coefficient having a sign inverse of its median; SPI, sum of pain intensities; SPID, sum of pain intensity differences.

also notes that whereas percussion pain and spontaneous pain in the
control group decreased from day 1 to day 4 and leveled off afterwards,
spontaneous pain in the experimental group was diminished at day 4
and elevated at day 5.
At day 7 (Table 4 and Supplemental Figure S2; available online at
www.jendodon.com), it was noted that both spontaneous and percus-
sion pain were less in patients in the experimental group. Other day 7
results were well-matched between the groups.
All patients seen at day 7 were also followed up at 6 months; results
obtained at 6 months are tabulated in Table 4 and illustrated in
Supplemental Figure S2 (available online at www.jendodon.com). No
sharp imbalance exists between groups. However, a trend toward fewer
periapical lesions and endodontic retreatment indications was observed
in the experimental group.
Discussion
Management of acute irreversible pulpitis by pulpotomy in
mature permanent teeth is widely recommended when the reference
etiologic treatment (endodontic treatment) cannot be done

TABLE 3. Raw Spontaneous and Percussion Pain Reported by Patients during the 7-day Waiting Period
Pain intensity
Variable Day 0 1 2 3 NA 0 1 2 3 NA
Spontaneous pain 1 18 14 6 1 8 10 20 10 0 7
2 20 18 0 1 8 10 26 4 0 7
3 20 17 1 1 8 13 24 2 1 7
4 35 3 0 1 8 19 17 2 2 7
5 29 7 1 1 9 23 14 2 1 7
6 32 6 0 0 9 24 15 0 1 7
7 34 4 0 0 9 24 15 0 1 7
Percussion pain 1 21 16 1 1 8 1 23 14 2 7
2 27 11 0 1 8 1 27 11 1 7
3 30 8 0 1 8 4 31 5 0 7
4 34 4 0 1 8 7 30 2 1 7
5 32 6 0 0 9 7 30 3 0 7
6 31 7 0 0 9 9 29 1 1 7
7 31 7 0 0 9 11 26 2 1 7
Methylprednisolone Pulpotomy
Randomization group
NA, not available.
Pain intensity measurement is described in text.

JOE — Volume 42, Number 1, January 2016 Methylprednisolone in Acute Pulpitis 5

CONSORT Randomized Clinical Trial
Figure 2. Pain daily variations during 7-day waiting period, illustrated by the polychoric ordered regression parameters’ posterior distributions. Box = 50%
highest posterior density (HPD) region (here always an interval), whiskers = 95% HPD interval, bar = median.
immediately (2). Some case series document the success rate of
pulpotomy during sometimes extended periods (5–7). Most
notably, Tronstadt (1) justifies the recommendation of pulpotomy
as the reference emergency management for acute irreversible pul-
pitis on the basis of a series of 1848 cases, for which 98% success
rate is claimed.
However, randomized clinical comparisons involving pulpotomy
are rare and compare different modalities of realization of a pulpotomy:
1. Various temporary interim medications were compared in a small
randomized, 6-armed clinical trial (8), which turned out to be
inconclusive but allowed the authors to report a high probability
of pain relief after pulpotomy (93% at day 7).
2. Two temporary restorative materials were compared in medium-
term (6 and 12 months) restoration after pulpotomy (9). These au-
thors found no differences in sealing tightness between the materials
but noted the clinical success rate of pulpotomy after a long interim
period (90% at 6 months.)
3. The effect of intrasulcular ketorolac tromethamine injection was
compared with a placebo as a preliminary to ‘‘pulp extirpation’’
in a small randomized trial, which was terminated early (10). The
authors decided to interrupt the trial because the ketorolac injection
was itself quite painful. In addition, the trial did not provide details of
the endodontic procedure results.
6 Bane et al.
To the best of our knowledge, this trial is the first clinically
oriented, randomized comparison of pulpotomy with an alternative
treatment. The seminal work of Gallatin et al (3) did not allow for
comparison of the clinical effects of pulpotomy and methylprednis-
olone injection. However, it demonstrated that the latter treatment
was not a placebo effect and hinted at an important pain relief ef-
fect. This clinical effect of methylprednisolone has been associated
with a drop in intrapulpal prostaglandin E2 concentration 1 day af-
ter injection (11). Similar pharmacologic mechanisms have been
proposed to explain the effectiveness of 30 mg preoperative pred-
nisolone administration per injection on postoperative pain in end-
odontics (12).
Our results suggest that pulpotomy results in a short episode of
periodontitis, objectified by percussion pain, which does not occur after
methylprednisolone administration.
The unavailability (for logistical reasons) of interim statistical an-
alyses led to the inclusion of 47 patients per group, resulting in a slightly
overpowered trial. Similar reasons prevented us from recording anal-
gesic consumption, which might have been a better indicator of pain
than self-reported estimations.
Our results show that methylprednisolone injection appears to
be more effective than pulpotomy for relief of acute irreversible pul-
pitis pain. They also provide limited proof that it is safe to use,
because no seriously dangerous event related to its use was reported.
JOE — Volume 42, Number 1, January 2016
 CONSORT Randomized Clinical Trial
TABLE 4. Six-month Results
Randomization to
Variable Prednisolone Pulpotomy Group effect 95% credible interval Pseudo p
Treatment – 6-mo follow-up 188.5  15.0 (6 NA) 190.7  7.9 (4 NA) 2.009 ( 6.971, 3.375) .230
delay (d)
Further dental visits before 6 mo 0 (0%) (6 NA) 3 (7%) (4 NA) 0.191 ( 1.038, 0.675) .333
Endodontic retreatment before 0 (0%) (6 NA) 1 (2%) (4 NA) 0.002 ( 0.822, 0.895) .498
6 mo
Re-restoration before 6 mo 0 (0%) (6 NA) 3 (7%) (4 NA) 0.197 ( 1.079, 0.649) .330
Other dental care before 6 mo 0 (0%) (6 NA) 1 (2%) (4 NA) 0.006 ( 0.864, 0.839) .495
Restoration acceptable at 6 mo 39 (95%) (6 NA) 40 (4 NA) 0.005 ( 0.869, 0.832) .494
Spontaneous pain at 6 mo
0 41 (100%) 40 (93%)
1 0 (0%) 2 (5%)
2 0 (0%) 1 (2%)
NA 6 (13%) 4 (9%) 0.741 ( 0.325, 1.881) .082
Percussion pain at 6 mo
0 41 (100%) 39 (91%)
2 0 (0%) 4 (5%)
NA 6 (13%) 4 (5%) 0.297 ( 0.651, 1.332) .273
Rx: periapical lesion at 6 mo 1 (2%) (6 NA) 5 (12%) (4 NA) 2.040 ( 4.944, 0.413) .027
Periodontal lesion at 6 mo 1 (2%) (6 NA) 1 (2%) (4 NA) 0.097 ( 0.770, 0.946) .410
Indication of endodontic 1 (2%) (6 NA) 5 (12%) (4 NA) 2.044 ( 5.015, 0.235) .031
retreatment
Pain intensity measurement is described in text.

The only undesirable event observed, which turned out to be incon-
sequential, appears to be similar to effects reported in rheumatology
(13). However, the small cohort size of this study makes it impos-
sible to rule out the possibility of rare but severe events. Finally,
our results suggest that no mid-term (up to 6 months) ill effects
were reported to result from this procedure. Its long-term effects
remain to be assessed.
The efficacy of the prednisolone procedure demonstrates that pul-
pitis pain can be satisfactorily relieved by pharmacologic means, which
are less invasive than pulpotomy and save scarce dental resources (end-
odontic equipment, dentist time). However, this procedure still re-
quires a dental chair and some manpower and cannot be transferred
to a physician lacking specific dental training. An anonymous reviewer
of a previous version of this article also noted that the cortical perfora-
tion needed for intraosseous injection may be technically difficult and is
not completely reversible.
The possibility of obtaining similar relief of pulpitis pain by oral
administration of all pharmaceutical agents should be studied
including oral corticoids and nonsteroidal anti-inflammatory drugs,
which should be evaluated for use in this indication, especially
when combined with analgesics and/or long-duration local anes-
thetics. The introduction of this medicinal analgesic protocol for pul-
pitis pain relief would allow physicians with little dental training to
manage such emergencies (provided they are trained in etiologic
and differential diagnosis of dental pain), thus allowing better alloca-
tion of scarce resources in clinical services that provide dental emer-
gency management.
Acknowledgments
The authors deny any conflicts of interest related to this study.
Supplementary Material
Supplementary material associated with this article can be
found in the online version at www.jendodon.com (http://dx.doi.
org/10.1016/j.joen.2015.09.003).
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