MANAGEMENT OF ENDODONTIC PAIN

- BEFORE, DURING AND AFTER

Dr. A. Subbiya
Prof and Head
Dept of conservative dentistry and endodontics
Sree Balaji Dental College
Chennai
• 60% avoid dental treatment due to
treatment pain
• Pain may worsen during the treatment
• Controlling pain, anxiety and fear is one of
the most important steps in pulpitits
treatment
 Cognitive
Sensory
Perception of Past experience
noxious
stimulus Memories
Culture/ Race

PAIN

Motivational Affective
Fear
The “drive” to stop Anxiety
Pain catastrophic
PAIN CONTROL: WHAT ARE OUR OPTIONS?

• Pre-op medication
• Local anaesthesia
• Post-op analgesia
PAIN MANAGEMENT – BEFORE TREATMENT
• Premedication
• Analgesics
• Antibiotics
• Anti-anxiety agents
• Steroids
• Benzodiazepines 
• others
 PREMEDICATION - ANALGESICS
• Preoperative ibuprofen or ketorolac has no significant effect
(Aggarwal V)
• Ibuprofen given 45 minutes before IANB is not effective to reduce pain ( Reader A)
• A combination of ibuprofen and paracetamol before IANB – no effect (Simpson)
• Premedication with ibuprofen and indomethacin significantly increased the success
rates of IANB (Parirokh)
•  Ibuprofen is an effective premedication (Modaresi)
• Paracetamol, Ibuprofen, and Aceclofenac significantly improved the efficacy
of maxillary infiltration anesthesia. (Ramachandran)

• Systematic analysis (Li et al)

NSAIDs might have some good effect and are safe on increasing the success rate of
IANB.
PREMEDICATION - ANTIBIOTICS
• Prescription of antibiotics in endodontic therapy is rarely necessary.
• Accurate endodontic treatment of necrotic canals is sufficient - no
need of antibiotic prophylaxis.(Contardo et al)
• Prophylactic dose of antibiotic before endodontic treatment of
asymptomatic, necrotic teeth had no effect on the endodontic flare-
up. (Pickenpaugh)
• Because of the emergence of bacterial resistance against most
known antibiotics, their use in endodontics should be highly limited
and restricted to a few cases.
(Siqueira JF)
OTHER DRUGS...

• Antihistamine may be useful in Atopic / hyperallergic patients

• Steroids - dexamethasone increased the success rate (Shahi)
• Acupuncture before the endodontic treatment increased the
effectiveness of IANB. (Jalali)
• Alprazolam did not improve the success of the IANB (Khademi) 
• Premedication with analgesics is effective
• Premedication for few days
• Ibuprofen – Paracetamol seems the best
• Antibiotics is not required in vital cases
• Anti-histamines may be useful in atopic patients
• Expected pain is less intense than unexpected pain.
• 84% of adults attending a dental clinic report sudden discomfort.
• In acute pain, anxiety may lead to normally non-painful stimulus to
be painful
TOPICAL ANAESTHESIA
• Available in form of gel, spray and patch.
• Lignocaine with Prilocaine is more effective than benzocaine
• Apply the topical anaesthetic and wait for one minute.
• Insert the bevel of the alone needle into the mucosa.
• Deposit 0.2 ml slowly – 5-10sec.
• Wait for a minute and then inject rest of the solution at 1ml per min.
• For IANB inject in one stroke – slowly!
VIBRATORY DEVICES
• Vibraject attaches to the barrel of the syringe and creates small
vibrations which makes injections almost painless.
• DentalVibe – injected close to vibrating tip
• It is based on the Gate Control Theory that nerve endings sense
vibrations first and then cannot transmit feelings of pain.

• The clinical efficacy of Vibraject remains controversial

• Not many studies on Dentalvibe
• expensive
LOCAL ANAESTHETIC
• There is no difference in pain with different needle size for either IANB or palatal
inj. (Abbot P)
• Plain lignocaine and plain prilocaine can produce less injection pain compared to
lignocaine with adrenaline (Kramp, Wahl, Meechan)
• Increasing the volume of lignocaine or concentration of epinephrine did not
increase IANB success (Wali)
• Speed of injection – Fast or slow?
• May not influence success of anaesthesia
• Slow IANB produced more success to maximal pulp stimulation than rapid IANB
(Kanaa)
• Slow injection – low pain – less apprehension - more patient comfort – more
success.
• Around 25% take more than 15 min for IANB and 8% take upto 30 min. (Nusstein)
ARTICAINE
•For mandibular molars and premolars
•IANB – no difference with lignocaine
•Buccal infiltration alone – effective
•Failed IANB + BI – more effective
•Maxillary molars
•100% effective and better than lignocaine (Sreenivasan et al)
•60% effective ( Ulusoy)

•Overall verdict
•Articaine is preferable as sole infiltration for any teeth and supplemental
buccal infiltration for mandilular molar
 “HOT TOOTH”

• Pulp diagnosed with irreversible pulpitis, with spontaneous,

moderate-to-severe pain
• Achieves lip/ soft tissue numbness but not pulpal anesthesia
• More commonly – mandibular molar

• Preop pain pain

• mild/moderate – more success
• severe preop pain – less success
(Subbiya)
SUPPLEMENTARY ANESTHESIA

• 13% of general practitioners encountered failure of anesthesia.

•  Most common failures - IANB injections.
• Particularly in teeth with spontaneous pain and irreversible pulpitis .

• TECHNIQUES
• Buccal infiltration for IANB
• Palatal infiltration for maxillary molar
• Intraligamentary injection
• Intrapulpal injection
• Intraosseus injection
BUCCAL INFILTRATION
• As discussed earlier IANB can be supplemented with Buccal
infiltration.
• Articaine is better than lignocaine.
• Increasing the volume of buccal infiltrations after a failed primary
IANB did not improve the anaesthetic success (Subbiya)

• Palatal injection for maxillary posterior teeth is effective.

INTRALIGAMENTARY INJECTION
• Solution injected via the periodontal ligament reaches the pulpal
nerve supply by entering the cancellous
• It is a form of intraosseous anaesthesia.
• 30 gauge short needle
• Needle bevel - face the alveolar wall.
INTRALIGAMENTARY INJECTION
• The needle is forced to maximum penetration until it is wedged
between the tooth and the crestal bone.
• Inject with pressure (approx 0.2ml).
• Feel a back pressure. Sustain for 20 sec.
• Anaesthesia is achieved within 30 sec
• Duration of anaesthesia is 10 – 15 min
• Conventional or specialized syringes can be used
• STA-System [Single Tooth Anesthesia System] - The Wand®
• 30-gauge or 27-gauge half-inch luer-lock needle
• 3 delivery rates: 0.005 mL/sec to 0.06 mL/sec
INTRAPULPAL INJECTION
• When all supplemental techniques fail
• Only possible if there is a small opening on the pulpal roof
• Any needle can be used
• LA solution / saline
• Back-pressure is mandatory
• Painful but successful
• patient should be informed of the pain expected in advance of the injection.
• Pain can be reduced by application of topical anaesthetic – not always
successful
• Onset – immediate
• Duration – 15 -20 min
INTROSSEUS ANAESTHESIA
• Stabident, X-tip etc
• > 90% successful
• Onset – immediate
• Duration – 15 -20 min
• Site selection
• Attached gingiva / alveolar mucosa
• Equidistant between adjacent roots
PULP EXTRIPATION
• Even if pulp extripation from root canals can be done with mild pain
give intra-radicular injection.
• Enter the root canal with rotary file rather than hand file
• Extripate with rotary file and determine working length.
INSTRUMENTATION
When can you expect more pain?
• Acute irreversible pulpitis and acute apical periodontitis (Parirokh)
• Hand files produced significantly more pain than rotary files.
(Gonzalez)
• Pain experienced during endo decreased with age
• Women experience more pain when compared to men
• More pre-op pain – more pain on access and instrumentation
(Subbiya)
INSTRUMENTATION
• There is no difference in pain with different instruments during
instrumentation
• Different instruments can also evoke different levels of pain post-
operatively
• Pain can be related to instrument design and method of
instrumentation (Subbiya)
• Crown-down technique can decrease the post-operative pain
• Higher incidence of PP should be expected after
manual instrumentation (Arias).
• Passive irrigation / negative pressure irrigation
• Irrigants do not influence postoperative pain (Almedia)
POST-ENDODONTIC PAIN
• The cause of the post-endodontic pain is
• Microbial

• Non-microbial
• Mechanical
• Chemical
MICROBIAL
• Microbes in apical region - 10⁶microbes
• "local adaptation syndrome“
• During instrumentation -extrusion of infected debris
• imbalance between microbes - immune system
• increases the inflammation
• Greater incidence of pain following treatment of teeth with necrotic
pulps.
(Siqueira JF)
PREVENTION OF MICROBIAL CAUSES

• Confine instrumentation within root canal system

• Adequate chemomechanical preparation
• Intracanal medicaments
• ICM - CHX alone and CaOH+CHX - less PIP
• Aseptic endodontic treatment
• Rubber dam
• Hermetic temporary filling
PREVENTION OF NON-MICROBIAL CAUSES
• Non-microbial causes - usually iatrogenic
• Overinstrumentation – accurate WL determination is important.
• In infected cases, overinstrumentation with
extrusion of infected debris.
• Apical extrusion of irrigants – passive irrigation

• Analgesics after instrumentation – decreases pain

• Ibu-Para may be more effective (Menke, Menhinick)
PREVENTION OF NON-MICROBIAL CAUSES
• Non-microbial causes - usually iatrogenic
• Overinstrumentation – accurate WL determination is important.
• In infected cases, overinstrumentation with
extrusion of infected debris.
• Apical extrusion of irrigants – passive irrigation

• Analgesics after instrumentation – decreases pain

• Ibu-Para may be more effective (Menke, Menhinick)
POST-OBTURATION PAIN

• Factors
• Female
• Molar tooth
• Size of periapical lesion
• History of post-preparation pain 
• Single-visit treatment
(Ng and Gulabivala)
MANAGEMENT OF POST-ENDODONTIC PAIN
• Inter-appointment pain
• Post-obturation pain
• Chronic pain
• Diagnosis, Definitive treatment and Drugs (Hargreaves)
MANAGEMENT OF POST-ENDODONTIC PAIN
• Diagnosis
• The current episode of pain may be coming from
• Another tooth
• Maxillary sinus
• TMJ-related condition
• Post-injection sequelae
• Definitive treatment
• Reassure the patient
• Re-instrumentation
• Incision and drainage
• Intracanal medicaments
• Occlusal reduction
MANAGEMENT OF POST-ENDODONTIC PAIN
• Re-instrumentation
• properly anesthetized prior to any treatment
• look for any missed canal
• Reconfirm working length
• thorough debridement with copious irrigation
• Suppurative exudation – open dressing - ?
MANAGEMENT OF POST-ENDODONTIC PAIN
• Incision and drainage
• establish drainage through the oral mucosa
• Re-enter the root canal system and debride
• Intracanal medicaments
• intracanal steroids, NSAIDs, steroid–antibiotic compound has
been shown to reduce pain.
• Occlusal reduction
• For all endodontic treatment?
• Certainly if patient comes back with pain
DRUGS
• Antibiotics
• If infection is beyond root canal system
• Routine use for all painful cases – NO
• NSAIDs
• Ibuprofen with or without Paracetamol
• Safe and effective
• Ketorolac
• Diclofenac
CHRONIC PAIN

• Pain that extends beyond the expected period of healing

• Often handled by a pain management team
• Drugs
• NSAIDs
• Muscle Relaxants
• Antidepressants
• Anticonvulsants
PSYCHOLOGICAL INTERVENTION TECHNIQUES
JERJES ET AL

• Distraction strategies - Visually interesting stimulus, music

• Sensory information - Procedure and typical sensations to be
expected, drill sound
• Perceived control - Arm-raising encouraged as pause signal
• Positive dental experience - Benefits of introduction to the
management by the dentist
Thank you all !