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International Journal of Dentistry and Oral Science (IJDOS)  /  IJDOS-2377-8075-08-5055

Effect Of Intracanal Analgesia To Control Interappointment Pain During Root Canal Treatment - A Literature Review


Nivedhitha1*, Sneha Pai2

1 Professor and Head, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University 162, Poonamallee High Road, Chennai 600077, Tamilnadu, India.
2 Department of Conservative Dentistry & Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India.


*Corresponding Author

Nivedhitha,
Professor and Head, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University 162, Poonamallee High Road, Chennai 600077, Tamilnadu, India.
Tel: +919840912367
E-mail: nivedhitha@saveetha.com

Received: April 28, 2021; Accepted: May 28, 2021; Published: May 30, 2021

Citation: Nivedhitha, Sneha Pai. Effect Of Intracanal Analgesia To Control Interappointment Pain During Root Canal Treatment - A Literature Review. Int J Dentistry Oral Sci. 2021;08(05):2632-2636. doi: dx.doi.org/10.19070/2377-8075-21000515

Copyright: Nivedhitha©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.



Abstract

Endodontic treatment is often associated with pain in most of the patients and so pain management in endodontics has always been of concern to all the dentists. In anticipation of pain during root canal treatment, the patients' anxiety levels shoot up which makes the treatment procedure difficult, disrupts scheduling and creates discomfort to the dentists. Interappointment pain during root canal treatment has been believed to be caused by acute inflammation in the periapical area. Several agents have been used for the management of this pain and various routes of administration have been studied for the delivery of these agents to manage pain effectively. This review would discuss the pathophysiology of endodontic pain, the agents used and the routes of delivery of these agents for the management of interappointment pain during root canal treatment along with a novel technique of administering the drug locally at the site of action with minimum concentration for effective pain control.


Full Text -HTML

1.Keywords
2.Introduction
3.Causes Of Interappointment Pain
4.Pathophysiology Of Interappointment Pain
5.Treatment Of Interappointment Pain
6.Conclusion
7.References

Keywords

Analgesia; Interappointment Pain; Mefenamic Acid; Aceclofenac; Local Drug Delivery.


Introduction

The frequency of interappointment pain during root canal treatment and the patients’ anxiety associated with it has created major concern among dentists regarding pain management. Also a positive correlation has been made between the preoperative apprehension and postoperative pain [1, 2]. Several studies have been carried out to assess the most effective method of analgesia and anesthesia to make endodontic treatment pain free.

Pain during endodontic treatment can be classified in to three sub headings: pain occuring before the initiation of endodontic treatment, pain during endodontic treatment and pain that develops after the treatment. Post endodontic pain is experienced by 25-40% of the patients undergoing endodontic treatment and it comprises interappointment pain and post obturation pain [3-6]. Interappointment pain is caused due to acute inflammatory reaction in the apical periodontal ligament which could be due to over instrumentation, extrusion of debris or medicament beyond apex, injury to the vital nerve or pulp tissue or due to occlusal trauma [7-10]. This inter appointment pain can be managed by occlusal reduction, use of antibiotics, corticosteroids or analgesics [11].

Previously our team has a rich experience in working on various research projects across multiple disciplines [12-42] Now the growing trend in this area motivated us to pursue this project.

This review will highlight the causes and mechanisms of interappointment pain along with the treatment approaches for its management.


Causes Of Interappointment Pain

Interappointment pain is caused due to mechanical, chemical or microbial injuries to the pulpal or periapical tissues during root canal treatment [43, 44]. It has been reported that the severity of inflammation is proportional to the magnitude of tissue damage [45].

Microbial injury has been proposed as one of the common causes of interappointment pain [44, 46]. This can be proved by the fact that interappointment pain is reported to be significantly higher in teeth with periradicular pathosis in comparison to teeth with vital pulps and healthy periapical condition [47, 48]. Mechanical and chemical causes when added up with the microbial involvement, interappointment pain is aggravated.

Microbial Causes

Interappointment pain is a result of imbalance between host and bacteria during intracanal procedures. There are a few circumstances where micro organisms cause inter appointment pain and these are dependent of several factors which are interlinked.

Presence Of Pathogenic Bacteria: Presence of pathogenic bacteria would initiate the inflammatory process and these bacteria are believed to be those involved with primary root canal infections. Moreover, their virulent forms would exaggerate the inflammatory response [49].

The Microbial Load and Microbial Synergism: More the microbial load, more exaggerated inflammatory response would be triggered resulting in postoperative pain. Also, most of the endodontic pathogens would exhibit virulence when present in association with other species due to synergistic microbial interactions [50-54].

Host Resistance and Environmental Cues: Host resistance is a deciding factor whether the infection will continue or not. Individuals usually present with varying patterns of resistance to infections and those with a reduced ability to resist the infection will be prone to develop clinical symptoms of inflammation after endodontic procedures, especially in infected root canals [55, 56]. A virulent prototype of an organism does not always express virulence and this virulence is activated only in the presence of certain environmental factors [57]. If the environment of the root canal is altered by intracanal procedures, it might provide optimum conditions for the microbial virulence which in turn aggravates interappointment pain.

Apical Extrusion Of Debris: This is one of the commonly cited reasons for the development of postoperative pain [44, 58, 59]. During chemo mechanical preparation, micro organisms are extruded in to the periapical space which initiates an inflammatory response, the severity of which depends on the load of organisms pushed into the periapex. This inflammation which tries to establish the equilibrium would result in interappointment pain.

Incomplete Instrumentation: Incomplete chemomechanical preparation would disrupt the balance with in the microbial community by eliminating some inhibitory species and leaving behind others which when overgrows would initiate inflammatory response resulting in inter appointment/post endodontic pain [60].

Secondary Intraradicular Infections: These infections are caused by microorganisms that weren’t a part of root canal infection but have gained entry into the root canal during the treatment. This could mainly be due to break in isolation during the treatment [61]. If the microorganisms causing secondary infection happen to be virulent, they multiply and initiate inflammatory response in the periapex causing post treatment pain.

Non Microbial Causes

Non microbial causes can also result in periapical inflammation and pain These are usually iatrogenic in origin. Non microbial causes consist of physical and chemical factors which on interaction with the periapical tissues, give rise to interappointment pain. The severity of the pain is controlled by the degree of damage to the periapical tissues, intensity of injury and the inflammatory response.

Mechanical Factors: Over instrumentation and overfilled root canals are common examples for mechanical factors causing interappointment pain. Over instrumentation with large sized instruments would not only damage the periapical tissues but also extrude the microorganisms into the periapical area resulting in inflammation and pain. Over extended filling materials would compress the periapical tissues resulting in pain.

Chemical factors: Intracanal irrigants and medicaments are toxic and are formulated for use within the root canals. Extrusion of these materials in the periradicular space would incite an inflammatory reaction resulting in post endodontic pain [62-66]. Over extended filling materials have also been found to chemically irritate the periapical tissues leading to pain.


Pathophysiology Of Interappointment Pain

Interappointment pain is as a result of acute inflammation in the periapical area. When the periapical tissue is injured, various chemical substances are activated which would initiate the inflammatory pathway resulting in vasodilation, improved vascular permeability and chemotaxis of inflammatory cells. The chemical mediators released from the inflammatory pathway include prostaglandins, leukotrienes, cytokines, oxygen derived free radicals and plasma derived factors [67].

These chemical mediators can incite pain by directly stimulating the sensory nerves or causing vascular permeability which results in exudation and edema which in turn causes pain [45, 68].


Treatment Of Interappointment Pain

An integrated approach or the 3D approach has been put forth by Hargreaves and Seltzer for the management of interappointment pain where the condition is first diagnosed following which definitive treatment and drugs are prescribed. Clinical and radiographic examination of the area is initially carried out to diagnose the ailing tooth and the severity of pain after which definitive treatment is initiated.

Definitive treatment includes.

Reinstrumentation

The symptomatic tooth is re entered, patency obtained and chemomechanical preparation is repeated with copious irrigation so that the leftover infected tissue, microorganisms, bacterial toxins and the inflammatory exudates are flushed out thereby relieving the localised tissue pressure in the periapical area [11].

Cortical Trephination; Incision and Drainage

These are invasive treatment protocols that are carried out in case the patient presents with swelling. These techniques immediately relieve the pressure exerted by inflammatory exudates or abscess over the periapical tissues and relieve interappointment pain [69, 70].

Intracanal Medicaments

Intracanal medicaments are commonly placed in the root canal during the interappointment period to control interappointment pain. Placement of medicaments would disinfect the root canal and relieve the inflammation thereby preventing the collection of exudates and compression of the periapical tissues. Several studies have been conducted where apart from calcium hydroxide, corticosteroids have also been proven effective for canal disinfection and relieving interappointment pain [71-73].

Occlusal Reduction

This is an invasive but effective technique for the management of interappointment pain [74]. Occlusal reduction would relieve the tooth from contacting the opposing tooth which would reduce the stimulation of periapical nociceptors and there by alleviates pain.

Drugs

The drugs commonly used to control interappointment pain are antibiotics and analgesics.

Antibiotics: Antibiotics were earlier prescribed frequently to patients undergoing endodontic treatment as a prophylactic measure to avoid interappointment pain. These drugs were prescribed as first line drugs to patients reporting with interappointment pain during endodontic treatment [75, 76]. With the upsurge of bacterial resistance due to widespread antibiotic use, it was indicated to use these drugs only if systemic manifestation of infection was evident [77].

Non Steroidal Anti Inflammatory Drugs (NSAIDs): These are commonly employed drugs for the management of interappointment pain in endodontics. NSAIDs act both centrally and peripherally by inhibiting the cyclooxygenase pathway there by inhibiting the release of mediators of inflammation [78, 79].

So far, oral route has been most widely used for administration of analgesics to manage endodontic pain. Infrequently used routes of administration of analgesics include intramuscular and submucosal drug delivery.

Frequent use of analgesics resulted in severe gastrointestinal side effects and this led researchers to look for an alternate drug or route of delivery [80]. In the mid 1900s, some researchers proposed the use of intracanal route of delivery of analgesics and corticosteroids after chemo mechanical preparation of the root canal and noticed significant reduction in interappointment pain of root canal treatment [10, 72, 81].

Intra canal drug delivery can therefore be developed as a novel technique for local drug administration to control interappointment pain. In the root canal, the pain site is very specific and the surface area is small which makes it possible for target oriented drug delivery. Also, the concentration of the analgesic required to attain analgesia is less when compared to the dosage required for systemic administration [80, 82]. With the local administration of the analgesic, the first pass metabolism is bypassed and the analgesic is deposited directly at the site of its action. Hence, intracanal administration of analgesics would.

? Reduce the side effects due to systemic use.

? Reduce the dosage of the drug required to achieve analgesia.

? Speed up the analgesic action of the drug.

? If effective, would eliminate the necessity of post procedural analgesic medication in any other form.

Our institution is passionate about high quality evidence based research and has excelled in various fields [42, 83-92].

The studies conducted in the past with intracanal administration of analgesics have used the drug in the form of a paste, moreover the dosages of the drug are not standardized and ready made formulations prepared for systemic use have been utilized. Further studies can be conducted with analgesic solutions that would easily percolate into the periapical area to control periapical inflammation. Also, standardization of drugs have to be carried out and preparations with plasma concentrations of the drugs can be formulated to check the effectiveness to control endodontic pain.


Conclusion

The causes of interappointment pain can be microbial, chemical or physical factors which irritate the periapical tissues and induce inflammation which is manifested as pain. The most conservative management of inter appointment pain included intracanal delivery of analgesics which not only acts fast but also bypasses the systemic side effects.

There are no studies on intracanal analgesic delivery conducted systematically with proper study design or drug standardization. Future studies can focus on using lower concentrations and standardization of the drug to assess effectiveness in the management of interappointment pain. Studies can also be designed to evaluate the effectiveness of intracanal analgesic in managing pain for both vital and nonvital teeth.


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