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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 52-56

Correlation of postoperative pain in vital versus nonvital teeth: A clinical prospective study


1 Department of Conservative Dentistry and Endodontics, Patna Dental College and Hospital, Patna, Bihar, India
2 Department of Oral Pathology, Dr. B.R. Ambedkar Dental College, Patna, Bihar, India
3 Department of Dentistry, IGIMS, Patna, Bihar, India
4 Department of Conservative Dentistry and Endodontics, North Bengal Dental College and Hospital, Siliguri, West Bengal, India
5 Kole Dental Clinic, Ichalkaranji, Maharashtra, India

Date of Submission07-Sep-2020
Date of Acceptance10-Mar-2021
Date of Web Publication28-Jun-2021

Correspondence Address:
Rashmi Issar
Department of Conservative Dentistry and Endodontics, Patna Dental College and Hospital, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jigims.jigims_1_20

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  Abstract 


Introduction: The success of root canal treatment is now above 97%. Today keeping pace with this rapidly evolving field in dentistry now single visit endodontics has become more of a compulsion rather than an option. However, to embrace this change, a scientific rationale along with clinician's and patient's acceptance is mandatory. The present study compares the postoperative pain in endodontically treated teeth in vital versus nonvital teeth.
Materials and Methods: Sixty patients between the age 16 and 60 years requiring root canal treatment of maxillary and mandibular single rooted teeth were selected. After access opening under rubber dam based on bleeding or absence of bleeding from the canals, three groups were divided Group I – 20 teeth were grouped as vital which showed bleeding from the canal, Group II – 20 teeth were grouped as nonvital which showed no bleeding from the canal but absence of periapical radiolucency, and Group III – 20 teeth were grouped as nonvital with periapical radiolucency. Single-visit endodontic was completed for all the teeth. Patients were asked to report about pain intensity on 1st day, 2nd day, 1st week, and 2nd week based on the scores from 0 to 3 with increasing intensity. The values were recorded and subjected to Pearson Chi-square test and Fisher's exact test.
Results: Out of 60 patients, eight patients had dropped out and 52 patients reported after 2nd week. Incidence of pain was calculated for each group at the end of 1st day, 2nd day, 1st week, and 2nd week using Chi-square test. Intragroup and intergroup comparison was carried out, and it was found to be statistically insignificant (P > 0.01).
Conclusion: The results of the present study favor single-visit endodontics in vital, nonvital teeth with and without periapical radiolucency. There was no significant difference in postendodontic pain in any of the groups which suggest that single-visit endodontics with stringent clinical protocol can be used in most of the teeth needing endodontic intervention.

Keywords: Nonvital teeth, periapical lesion, single visit endodontics, vital teeth


How to cite this article:
Issar R, Ranjan S, Singh P, Lakiang D, Kole R. Correlation of postoperative pain in vital versus nonvital teeth: A clinical prospective study. J Indira Gandhi Inst Med Sci 2021;7:52-6

How to cite this URL:
Issar R, Ranjan S, Singh P, Lakiang D, Kole R. Correlation of postoperative pain in vital versus nonvital teeth: A clinical prospective study. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2021 Sep 24];7:52-6. Available from: http://www.jigims.co.in/text.asp?2021/7/1/52/318916




  Introduction Top


With the advance of knowledge and skills and the use of impeccable materials and equipments, endodontic treatment nowadays has become a viable treatment to save the tooth, with success rate as high as 97%. Contemporary endodontics is associated with three-dimensional (3D) imaging, rubber dam isolation, magnifying devices, electronic apex locators, highly engineered engine-driven nickel–titanium files, ultrasonic instrumentation, and the 3D obturation techniques.[1],[2]

Although multiple visit endodontic intervention has stood through time, the leap in technology has led to a change in this concept. Disadvantages such as inter appointment contamination, flare-ups caused by leakage or loss of temporary seal, prolonged time taken leading to patient fatigue, operator fatigue, inability to provide esthetic restorations in time in case of traumatically damaged crowns, and discontinued treatment, leading to failures has led to paradigm shift toward single visit endodontics.[3]

Single-visit randomized controlled trials take less time, is cost-effective, prevent contamination and bacterial regrowth, is less stressful to patient regarding anesthesia, and instrumentation related to treatment. Its main disadvantage is that there is no possibility for checks such as culture and reevaluation of tissue response after treatment procedure.[4],[5]

Postoperative pain is one of the major factors that can have a detrimental effect on the quality-of-life of patients submitted to root canal treatment. Although the success of endodontic treatment is highly related to the elimination or reduction of postendodontic pain, many clinical studies have reported varying degrees of pain, ranging from 25% to 40%.[6],[7],[8],[9],[10],[11]

Certain factors may influence the progression of postoperative pain such as a history of preoperative pain and the need for re-treatment. Although microorganisms are usually regarded as the most common cause of postoperative pain, other causes include mechanical or chemical injury to pulpal or periradicular tissues. There is a clear indication of interactions between periapical tissues and microorganisms, because flare-ups are more likely to occur in necrotic cases than in vital cases. This could indicate a clear relationship between pulp status and postoperative pain, even after successful endodontic therapy.[12],[13],[14],[15]

However, limited data regarding the relationship between postoperative pain and the vitality of the pulp before endodontic treatment are available in the literature. In irreversible pulpitis, endodontic therapy is currently the most frequently offered method to relieve pain. The completion of endodontic therapy in a single appointment has been currently used in the study.[16],[17],[18],[19]

The present study compares the postoperative pain after single-visit root canal treatment in single rooted vital teeth, nonvital teeth, and nonvital teeth with periapical radiolucency after 24 h, 48 h, 1 week, and 2 weeks after the treatment.


  Materials and Methods Top


Sixty patients between the age 16 and 60 years requiring root canal treatment of maxillary and mandibular single-rooted teeth were selected from the Department of Conservative Dentistry and Endodontics, Patna dental college and Hospital.

The inclusion criteria were asymptomatic single-rooted teeth requiring endodontic intervention, sound periodontal status, no history of sinus tract, and trauma. The exclusion criteria were weeping canal, periapical radiolucency more than 3 mm × 3 mm, preoperative pain, patient on analgesics preoperatively, and tooth to be used as abutments or under overdentures.

All the root canal treatments were performed in single visit. The patients were explained about the procedure and the study. Pulp vitality testing was done using electric pulp tester (Waldent). Preoperative digital IOPA X-rays were taken to assess the anatomy of the canal and the peripaical area. Local anesthesia 2% Lignox was administered to those teeth receiving treatment.

After access opening under rubber dam based on bleeding or absence of bleeding from the canals, three groups were divided.

  • Group I – Twenty teeth were grouped as vital which showed bleeding from the canal
  • Group II – Twenty teeth were grouped as nonvital which showed no bleeding from the canal, but the absence of periapical radiolucency
  • Group III – Twenty teeth were grouped as nonvital with periapical radiolucency.


Working length was determined by RVG (Vatech RVG EZ Sensor, Classic) and apex locator (Dentaport ZX, J. Morita). Biomechanical preparation was done by Neo Endo flex rotary files after glide path preparation by proglider (Densply) upto #25.06 and the apex gauged. After gauging if the canals needed further preparation, it was prepared accordingly up to #30.06. Balanced force technique was used and for irrigation 3% NaOCl (Septodont) followed by 17% EDTA (Pyrax) for removal of smear layer. Obturation was completed using vertical heat compaction (Eighteeth Fast Pack) and postendodontic restoration done by dental composite 3M ESPE). Self-report questionnaires were given to patient to be filled on 1st day, 2nd day, at the end of 1st week, and at the end of 2nd week. The patient was asked to report about pain intensity on these days based on the score written in the form.

  • 0 – No pain
  • 1 – Mild pain requiring no analgesics
  • 2 – Moderate pain requiring analgesics
  • 3 – Severe pain not relieved by medication and requiring palliative treatment.


Statistical analysis

Statistical analysis was done using Pearson Chi-square test and Fisher's exact test.


  Results Top


After 2 weeks out of sixty patients, 52 were available for follow-up. Two patients dropped from Group I to three patients each from Group II to III. Incidence of pain was calculated for each group at the end of 1st day, 2nd day, 1st week, and 2nd week using Chi-square test. Intragroup comparison was carried out, and it was found to be statistically insignificant. At the end of 1st day, 46.2% of cases had no pain, 34.6% of cases had mild pain, and 19.2% of cases had moderate pain. In no case, a reading of 3, i.e., severe pain was seen in any patient. The Chi-square test after 24 h was insignificant [Table 1].
Table 1: Pain at the end of 1st day

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At the end of 48 h, 72.26% of patients in Group I and III showed no pain, while a total 28.84% of patients had mild pain after 2 days. Chi-square test was not significant [Table 2].
Table 2: Pain at the end of 2nd day

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At the end of 1st week, only one patient each in Group I and III showed mild pain and all the other exhibited no pain at all with a reading of 0. The Chi-square test was nonsignificant [Table 3].
Table 3: Pain at the end of 1st week

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At the end of 2nd week, only one patient in Group III had a score of 1 rest none of the patient had any pain. The Chi-square test was significant (P < 0.05) [Table 4].
Table 4: Pain at the end of 2nd week

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A drastic decline to insignificant levels of pain (Score 1) was observed in group I & II from 1st day to 2nd week of observation [Graph 1]. [Graph 2] compares the score 2 i.e. significant pain levels of all the groups. By the end of 1st and 2nd week this score for all the groups becomes nil.




  Discussion Top


Single-visit endodontics has been a leap of faith for many specialist and general dental practitioners who though were not free of doubts in terms of its success and patient cooperation. Pain, an unpleasant emotional experience, is the sole reason for seeking emergency endodontic intervention, persistence of which not only raises questions on the treatment planning but also creates an embarrassing scenario for the experienced clinician. Missed strands of pulp tissue, possible leakage of irrigant beyond the apex, failure to disocclude the tooth causing mechanical allodynia, and noncooperation of the patient to follow postoperative instructions could be the cause for sustained postobturation pain. Coexistence of periodontal/periradicular lesion, persistent anaerobic infection, or external root resorption may also attribute to postendodontic pain. Today most studies recommend the use of a single-visit endodontics in vital teeth and asymptomatic nonvital teeth. However, a nonvital tooth with periapical radiolucency still remains a dilemma.[9],[20]

In this study, sixty patients requiring endodontic treatment in single-rooted teeth were selected, and single-visit endodontics was performed. They were divided into three groups: Group I – vital teeth, Group II – nonvital teeth, and Group III – nonvital teeth with periapical radiolucency. After 2 weeks, the patients were recalled with the questionnaire; they were given to assess their pain at the end of 1st day, 2nd day, 1st week, and 2nd week. The postoperative pain in this study was scored from 0 to 3, in which 0 and 1 was insignificant pain and 2 and 3 was significant pain. None of the patients in anytime of follow-up marked a reading of 3 which would have required an emergency appointment and palliative treatment.

To eliminate interindividual differences, random selection of patients with only one tooth for treatment was done. Alaçam and Tinaz in his study stated that multiple teeth in the same patient could not be assessed independently for postoperative pain levels.[21]

In the present study, the incidence of significant pain, i.e., a score of 2 for Group I (vital teeth) was 27.8% after 24 h, 11.1% after 48 h, and 5% after 1st week. In a similar study conducted by Fox et al., 10% of patients reported significant pain at the end of 48 h and 2% reported spontaneous pain at the end of 1 week. Bhagawat and Mehta studied the correlation of pain and single-visit endodontics and reported an incidence of 24% moderate or significant pain at the end of 24 h and showed none of the teeth exhibiting severe pain. Both the studies by Fox et al. and Bhagawat and Mehta concur well with the present study results of Group I i.e., vital teeth.[22],[23]

In the present study, the incidence of significant pain was 17.6% at the end of 1st day and 11.76% at the end of 2nd day for Group II (nonvital teeth without periapical radiolucency). Riaz et al. compared the postoperative pain in asymptomatic necrotic teeth and teeth with periapical lesion in sample size of sixty patients. They treated the asymptomatic group in single appointment and the later cases in two appointments. The pain was scored by VAS score and 5–10 score was described as significant pain which was present in 9.6% of patients at the end of 48 h for asymptomatic necrotic teeth. The above results are the same as the present study. In a study by Oliet, 264 nonvital teeth were endodontically treated in single visit and 10.6% incidence of pain following obturation after 24 h and no pain at all after 1 week was observed. The results in this study are in accordance with the present study.[24],[25]

In Group III in the present study, incidence of postoperative significant pain remained the same after 24 h and 48 h, i.e., 11.76%. Not many studies in the literature advocate the use of a single visit endodontics in nonvital teeth with periapical radiolucency and those documented have shown conflicting results. In a study by Molander et al., clinical symptoms during their long-term follow-up of teeth with different sizes of peripaical lesions were very rare. Even in the present study, only two teeth with periapical lesion of <3 mm diameter had a score of 2.[26]

In the present study, there was no significant difference in postoperative pain between vital, nonvital, and teeth with periapical lesion (P > 0.01). Ince et al. did a similar comparative study on 306 patients and found that there was no significant difference in postoperative pain between vital and nonvital teeth. Genet et al. studied 13 preoperative and operative factors and their association with the incidence of postoperative pain after root canal treatment. They showed a positive correlation between postoperative pain and nonvital tooth. Furthermore, they found increased incidence of pain in teeth showing periapical radiolucency of more than 5 mm. The results contradict our study which may be due to differences in case selection and methodology.[15],[27]

The limitations of the present study was no correlation with the preoperative pain of the offending tooth, no account of other systemic factors affecting the outcome, and inclusion of only single-rooted teeth.


  Conclusion Top


The present study concludes that there was no significant difference in pain between vital, nonvital, and nonvital teeth with periapical radiolucency. Within the limits of the study, we can advocate single-visit root endodontics in vital and nonvital teeth with and without periapical radiolucency. It has shown encouraging result and is definitely a promising treatment option in routine endodontics as the incidence of pain was distributed evenly among all the groups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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