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International Journal of Dentistry and Oral Science (IJDOS)  /  IJDOS-2377-8075-08-5058

Evidence Based Clinical Practice Guidelines For Management Of Acute Pain With Apical Periodontitis


Surendar1*, Srujana Hemmanur2

1 Senior Lecturer, Department of Conservative dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-77, India.
2 Post Graduate Student, Department of Conservative dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-77, India.


*Corresponding Author

Surendar,
Senior Lecturer, Department of Conservative dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai-77, India.
E-mail: surendars.sdc@saveetha.com

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

Citation: Surendar, Srujana Hemmanur. Evidence Based Clinical Practice Guidelines For Management Of Acute Pain With Apical Periodontitis. Int J Dentistry Oral Sci. 2021;08(05):2649-2652. doi: dx.doi.org/10.19070/2377-8075-21000518

Copyright: Surendar©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

Introduction: Acute apical periodontitis (AAP) or symptomatic apical periodontitis is a common endodontic diagnosis and requires immediate attention as the patient may present with moderate to severe pain. However, an array of symptoms may be presented which may lead us to a collective diagnosis of AAP. The management protocol of AAP is not standardised throughout the world and is seen to depend on personal choice. A need to establish standardised protocol for AAP is thus imperative.
Aim: This article gives an overview on the management of AAP and suggests a sequential approach for pain management in cases presenting with symptomatic apical periodontitis.
Materials and Methods: Randomised clinical trials, Systematic reviews, literature reviews and previously published clinical practice guidelines that deal with the management of acute apical periodontitis (AAP) were selected and data extracted.
Results: A protocol based on the existent information was suggested for the management of pain caused by acute apical periodontitis.
Conclusion: Pain management is an essential step for patient management and needs to be focused on as pain alleviation requires immediate attention.


Full Text -HTML

1.Keywords
2.Introduction
3.Materials and Methods
4.Clinical Presentation
5.Treatment Options
6.Protocol For Management Of Acute Pain In Aap
7.Conclusion
8.References

Keywords

Acute; Pain; Periodontitis; Relief; Rcts.


Introduction

Clinical practice guidelines as mentioned by Field et al are “systematically developed statements to assist practitioners and patients in arriving at decisions on appropriate health care for specific clinical circumstances” [1]. Clinical practice guidelines guide us towards formulation of a consolidated protocol that is evidence based, is valid, transparent, inclusive of all the clinical scenarios given under a subheading and accessible to everyone who needs them [2]. Factors like prevalence of a disease, the burden that an illness causes, relevance to local practice patterns, amount of variation in practice patterns, cost management and availability of evidence guide in selection of topics for clinical practice guidelines [3].

Acute apical periodontitis (AAP) happens to be an inflammatory condition of the periapical tissues that usually results from irreversible pulpitis and/or pulpal necrosis. Although chemical and physical factors may result in pulpitis, majority of cases have a microbial cause, usually secondary to either dental caries or trauma [4]. AAP is an inflammatory process rather than infectious however some bacteria has been demonstrated in the periapical region [5]. Patients with AAP present with pain from mild to severe in nature. With moderate and severe pain as presentation, the management becomes an endodontic emergency [6]. Emergency management of acute apical periodontitis (AAP) accounts for 2% to 6% [7]. Pain has been one of the most common symptoms of a diseased state and can be considered as a protective mechanism through which the body notifies of a harmful stimulus [8]. Pain thus becomes the most common symptom that patients present to a dentist. The patient approaching a dentist in most of the scenarios experience pain and discomfort [9].

Previously our team has a rich experience in working on various research projects across multiple disciplines [10-24]. Now the growing trend in this area motivated us to pursue this project.

Pain management is more or less based on personal choices rather than following a stringent protocol. The aim of the current study is to formulate a protocol for the management of acute pain caused by apical periodontitis in adult patients.


Materials and Methods

Study Identification

MEDLINE and EmBase, SCOPUS, Web of Science and Google scholar were thoroughly searched for articles with search words as acute pain, acute apical periodontitis, analgesics, antibiotics, surgical management, etc and their synonyms. The search was repeated for all credible interventions of pain management. Pharmacotherapeutics, non-surgical measures like endodontic management, surgical intervention, extraction, occlusal adjustment and no treatment were investigated.

Study Selection

Randomised clinical trials, Systematic reviews, literature reviews and previously published clinical practice guidelines that deal with the management of acute apical periodontitis (AAP) were selected.


Clinical Presentation

The clinical presentation of AAP appears in a wide array of symptoms. The progression of AAP from inflamed pulp is almost always inevitable, hence the diagnosis may be tricky. An incorrect diagnosis may lead to in appropriate management which takes a toll on both the patient and the dental surgeon. Patients with AAP usually present with dull, throbbing and pain that is constant; absence of swelling; a delayed positive or negative response to pulp vitality testing; absence of thermal sensitivity of the tooth; and pain on biting or percussion with often reports of slight extrusion of the tooth in the socket [7, 25, 26]. Radiographic changes such as widening of the periodontal ligament space may be present, but frank radiolucency will not be evident. Vitality tests have reportedly been affected by factors like the amount of residual pulp, number of roots and root canals, status of calcification, size and type of restoration on the tooth in question and habits [27]. Proper history taking and clinical as well as radiographic evaluation shall lead us to correct diagnosis.


Treatment Options

Amongst the various options available for management of acute pain as a result of symptomatic apical periodontitis, the ones mentioned in texts and practiced widely are pharmacotherapy, necrotic pulp extirpation with or without chemomechanical disinfection of the root canal space, intracanal medicament of various analgesics, antibiotics or corticosteroids, non surgical endodontic therapy, occlusal adjustment and no treatment per say.

Sutherland et al suggested the use of systemic NSAIDs in conjunction with non surgical endodontic therapy for the management of AAP. The use of antibiotics was not recommended as apical periodontitis is an inflammatory process. No significant benefit upon use of systemic antibiotics, intracanal treatment with combination of steroid and antibiotic and trephination through attached gingiva has been reported [7]. A clinical practice guidelines by Glenny and Simpson suggested the initiation of nonsurgical endodontic therapy (root canal) on the affected tooth as soon as possible. An appropriate dose of analgesics either preemptive or post operatively must be prescribed for pain control. Extraction should be considered in cases with poor prognosis. Relieving of occlusion in case of hyperocclusion is an alternative but the relief in pain occurs in around 12 hours [28]. However, the most cardinal treatment option is endodontic management of the affected tooth [26].

A cochrane review by Moore et al, suggested the use of OTC analgesics for management of acute pain. It is surprising that a maximum of 50% of pain relief is obtained by in take of oral analgesics alone. However, the endodontic diagnosis is not mentioned in this study [29]. Many authors have mentioned the ineffectiveness of use of systemic antibiotics in management of acute dental pain as a result of symptomatic apical periodontitis, This can be attributed to the nature of disease that does not involve microbial infection. However, apical abscesses should be managed with systemic antibiotics [30-33]. A recent RCT concluded chemomechanical disinfection and extirpation of necrotic pulp without chemomechanical disinfection as an effective method of pain alleviation in patients with symptomatic localised apical periodontitis with no mean difference in either groups [34, 35]. Hence, in patients where immediate canal disinfection cannot be done, pulpal extirpation must be done to relieve pain.

Amongst newer techniques for pain management in patients with symptomatic apical periodontitis is acupuncture [36]. Also, intracanal cryotherapy helps in management of pain in conjunction with chemomechanical preparation along with avoidance of postoperative systemic analgesics [37].

Our institution is passionate about high quality evidence based research and has excelled in various fields [38-48].


Figure 1. Suggested protocol for the management of pain caused by acute apical periodontitis.

Protocol For Management Of Acute Pain In Aap

Endodontic diagnosis of the affected tooth must be done effectively. An endodontic management of the affected tooth must be initiated. It is advisable to prescribe a pre-emptive analgesic to ensure patient cooperation and pain control prior to and during the endodontic therapy. Occlusal adjustment must be done such that the affected tooth is relieved of occlusion. Access to all the root canals must be established and they should be adequately disinfected. In case complete disinfection cannot be achieved, the pulpal tissue must be removed so as to effectively reduce pain. A postoperative analgesia is recommended. Preferably two-visit endodontic therapy should be performed.


Conclusion

Management of pain is extremely essential. In patients with symptomatic apical periodontitis, it becomes all the more indispensable. Various options exist for management of pain of which an individual selects the plans which suits them the most. A guide to immediate pain management is a prerequisite and hence, must be emphasised on. However, more clinical trials comparing different parameters need to be performed to arrive at a solid and consistent finding.


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