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International Journal of Dentistry

Volume 2012, Article ID 310467, 5 pages
doi:10.1155/2012/310467

Clinical Study
Postoperative Pain after Root Canal Treatment:
A Prospective Cohort Study

M. Gotler,1 B. Bar-Gil,2 and M. Ashkenazi1

1 Department of Pediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University,
69978 Tel-Aviv, Israel
2 Departments of Oral Pathology and Oral Medicine, The Maurice and Gabriela Goldschleger School of Dental Medicine,

Tel Aviv University, 69978 Tel Aviv, Israel

Correspondence should be addressed to M. Ashkenazi, [email protected]

Received 31 August 2011; Revised 10 November 2011; Accepted 9 January 2012

Academic Editor: Iris Slutzky-Goldberg

Copyright © 2012 M. Gotler et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Aim. To evaluate the incidence and severity of postendodontic treatment pain (PEP) subsequent to root canal treatment (RCT)
in vital and necrotic pulps and after retreatment. Methodology. A prospective study. Participants were all patients (n = 274) who
underwent RCT in teeth with vital pulp, necrotic pulp, or vital pulp that had been treated for symptomatic irreversible pulpitis or
who received root canal retreatment, by one clinician, during an eight-month period. Exclusion criteria were swelling, purulence,
and antibiotic use during initial treatment. A structured questionnaire accessed age, gender, tooth location, and pulpal diagnosis.
Within 24 h of treatment, patients were asked to grade their pain at 6 and 18 hours posttreatment, using a 1–5 point scale. Results.
RCT of teeth with vital pulp induced a significantly higher incidence and severity of PEP (63.8%; 2.46 ± 1.4, resp.) than RCT of
teeth with necrotic pulp (38.5%; 1.78 ± 1.2, resp.) or of retreated teeth (48.8%; 1.89 ± 1.1, resp.). No statistical relation was
found between type of pain (spontaneous or stimulated) and pulp condition. Conclusion. RCT of teeth with vital pulp induced a
significantly higher incidence and intensity of PEP compared to teeth with necrotic pulp or retreated teeth.

1. Introduction treatment and did not require active treatment were excluded
from those studies [6].
Prevention and management of postendodontic pain (PEP) The relationship between incidence and intensity of
is an integral part of endodontic treatment. Informing p- flares-ups and the vitality of the treated teeth has been inves-
atients about expected postendodontic pain (PEP) and pre-
tigated, yet with conflicting results. Mor et al. [7] found that
scribing medications to manage it can increase patient conf-
flare-ups more often followed endodontic treatment in non-
idence in their dentists, increase patients’ pain threshold, and
vital teeth and after retreatment than in vital teeth. However,
improve their attitude toward future dental treatment [1, 2].
Harrison et al. [8, 9] reported that the incidence and intensity
According to previously published data, pulp therapy and
of flare-up were unrelated to tooth vitality. No correlation
root canal treatment (RCT) induce more frequent and more
has been found between pulp status and any PEP [10, 11].
severe postoperative pain than do other dental operative pro-
cedures [3, 4]. In the literature, reported frequencies of PEP PEP (not limited to flare-up) is very frequent after endo-
range from 1.5 [5] to 53% [3]. The large range is apparently dontic treatment, and more than 50% of those who feel any
due, in large part, to differences in definitions of postendo- PEP experienced severe pain [3]. Nevertheless, no study has
dontic pain. Most studies that investigated the prevalence of evaluated the incidence and severity of PEP after re-treat-
postendodontic pain referred to flare-up, which was defined ment and after initial RCT of teeth with vital or necrotic pulp
as severe pain and/or swelling after endodontic treatment, [3].
requiring an unscheduled appointment and active treatment. The purpose of this study was to evaluate the incidence,
Therefore, patients who experienced pain after endodontic severity, and types of PEP presenting after root canal
2 International Journal of Dentistry

treatment in teeth with vital or necrotic pulp and after re- dissolved by xylene. The working length was determined by
treatment. Root ZX apex locator (J. Morita, California, USA). Canals
were irrigated with 5 mL of 3.5% NaOCl and sterile saline
and obturated with laterally condensed gutta-percha and
2. Materials and Methods AH26 sealer (the obturation length was determined by the
2.1. Study Population. This is a prospective study of individ- working length and was 0.5–1 mm short of the radiographic
uals who underwent RCT in teeth with vital pulp, necrotic apex). The duration of treatment ranged between 45 and 60
pulp, or vital pulp that had been treated for symptomatic ir- minutes.
reversible pulpitis, or who received retreatment of the root
canal, by one endodontic clinician during an eight-month 2.5. Determination of Pulp Status. The pulp status was deter-
period mined and recorded as vital only when the tooth responded
A structured questionnaire accessed age, gender, tooth immediately before treatment to a cold stimulus (CO2 snow)
location, and pulpal diagnosis (vital pulp, previously ini- and/or there was evidence of haemorrhage on opening the
tiated therapy, or necrosis). The Ethics Committee of Tel pulp chamber. The pulp status was recorded as nonvital if
Aviv University approved the study, and all patients signed there was no response to cold and no evidence of haemorrh-
informed consent. age on opening. Periapical pathology status was determined
by a periapical radiographic evaluation.
2.2. Inclusion Criteria. Inclusion criteria were treatment of
2.6. Evaluation of Postendodontic Pain and Use of Analgesic
only one tooth, completion of treatment in one session, and
Drugs 24 h Postoperatively. The treating dentist (BB) inform-
the absence of preoperative pain (otherwise the treatments
ed the patients that PEP may develop and suggested they take
were preformed in two sessions). Indications for treatment
Acetaminophen to relieve severe pain. A student (MG), un-
were (1) teeth with vital healthy pulp that were treated for
aware of the treatments performed, telephoned patients
prosthetic reasons. These teeth were treated by the endodon-
within 24 h postoperatively. She asked them to grade the level
tic practitioner only (BB); (2) teeth with previously initiated
of pain they felt 6 and 18 h after treatment, using a con-
therapy consequent to symptomatic irreversible pulpitis,
tinuous 1–5 point scale (1: no pain, 2: mild pain, 3: moderate
which were dressed with anti-inflammatory medicine (Led-
pain, 4: severe pain and 5: very severe/unbearable pain),
ermix paste, Haupt Pharma GmbH, Wolfratshausen, Ger-
which they had seen when they signed the consent form.
many); (3) teeth with necrotic pulps (diagnosed by a nega-
Patients were also asked to specify the type of pain from
tive response to cold stimulation and an absence of blood on
which they suffered (spontaneous or stimulated by masti-
entry to the root canal), with or without apical periodontitis
cation or palpation). Additional explanations about the scale
as evidenced by a periapical radiograph, but without preop-
were provided by the student, as necessary, until clarity was
erative pain; (4) teeth that were designated for endodontic
reached. Patients were asked about their use of analgesic
retreatment due to apical periodontitis or prosthetic reasons,
drugs following the treatment.
but without preoperative pain.
2.7. Statistical Analysis. The independent student’s t-test and
2.3. Exclusion Criteria. Exclusion criteria were the presence one- or two-way variance test were used to compare the
of teeth with symptomatic irreversible pulpitis, preoperative continuous variables between groups. Chi-square was used
pain, or necrotic pulp associated with clinical symptoms such to compare frequencies of categorical variables. Differences
as swelling or purulence. In addition, patients who were were considered significant when probabilities were less than
being treated with antibiotics were also excluded from the 0.05.
present study.
3. Results
2.4. Operative Endodontic Treatment. Maxillary teeth were
anaesthetized before treatment by infiltration and mandibu- 3.1. Patients and Treated Teeth. During the study period, 274
lar teeth by mandibular alveolar nerve block, using one car- individuals met inclusion and exclusion criteria. All patients
tridge of Lidocaine 2% with 1 : 100,000 epinephrine or Mepi- responded to the questionnaire (100% response rate). The
vacaine 3% (in patients for whom epinephrine was contrain- distribution of patients according to age, gender, and pulp
dicated), using 27 gauge needles. Local anesthesia was condition is presented in Table 1. Treated teeth comprised 97
delivered to all teeth that were treated or that were candidates (35.4%) anterior teeth, 89 (32.5%) maxillary molars, and 88
for retreatment of root canals, to prevent the evocation of (32.1%) mandibular molars.
pain from pressure of rubber dam clamps on the gingiva or
from over instrumentation, leakage of root canal irritants, or 3.2. Incidence and Intensity of Postendodontic Treatment Pain
overfilling material.
In all operative procedures, a rubber dam was applied Six h after Treatment. The mean incidence of PEP was 54.7%
immediately after delivery of local anesthesia. The endodon- (150/274). No pain (degree 1) was reported in 45.3% of the
tic treatment included accessing the root canal(s), hand in- patients (124/274). A low level (degree 2) was reported in
strumentation for extirpation, debridement, and shaping the 17.5% (48/274), moderate level in 20.4% (55/274), and a
canals, as necessary. In retreatment, the gutta-percha was high level (degrees 4 and 5) in 17.1% (47/274).
International Journal of Dentistry 3

Table 1: Patient distribution according to gender, age, and treated teeth for each of the treatment groups.

Treatment groups Number of patients∗ (%) Gender M/F Age (Y) Tooth type (anterior/max molar/mand molar ∗ )
Vital pulp 141 (51.5) 52/89 50.9 36/51/54
Necrotic pulp 52 (19) 24/28 56.4 31/11/10
Retreatment 81 (29.6) 26/55 45.1 30/27/24
∗
max molar: maxillary molar; mand molar: mandibular molar.

Table 2: Incidence and intensity of post-endodontic pain (PEP) with necrotic pulp or retreated teeth. This is in accordance
(Scale 1–5), 6 and 18 h after treatment. with Levin et al. [3] who showed that 53% of patients
receiving root canal treatment reported PEP; of them, only
6 hours 18 hours
21% reported a low level of pain. In contrast, other studies
Treatment Incidence Intensity Incidence Intensity showed lower frequency even for single appointment groups
groups number (%) mean ± SD number (%) mean ± SD
[6, 12, 13]. However, those studies included only patients
Vital pulp 90 (63.8) 2.46 ± 1.4 73 (51.8) 2.00 ± 1.2 with flare-up; in the present study we included all patients
Necrotic who reported any level of PEP.
20 (38.5) 1.78 ± 1.2 18 (34.6) 1.56 ± 0.9
pulp Another factor that may contribute to the higher freque-
Retreatment 40 (49.4) 1.89 ± 1.1 36 (44.4) 1.81 ± 1.1 ncy of PEP in the present study is that root canal treatment
P value 0.003 0.001 NS NS was performed at a single visit. Single-visit treatment has
been shown to result in higher frequency of PEP, and con-
sequently higher consumption of analgesics [6, 10, 13–15].
18 h after Treatment. The mean incidence of PEP was 46.4% Nevertheless, the main advantages of single visit treatment
(127/274). No pain (degree 1) was reported in 53.6% are the reduced time and added convenience for both patient
(147/274). A low level of pain (degree 2) was reported in and dentist, without increasing short or long complications
22.3% (61/274), a moderate level in 13.9% (36/274), and a [14].
high level (degrees 4 and 5) in 10.2% (28/274). Evidence in the literature of the effect of pulp status (vital
or necrotic) on the incidence and severity of PEP is inconclu-
3.3. Effect of Pulp Condition on PEP and Analgesic Use. Six sive. Our findings concur with those of Clem [16] and Cal-
hours posttreatment, incidence and intensity of PEP were houn and Landers [17], Marshal and Liesinger [11], Fox et al.
higher among patients who received RCT in teeth with [18], and Undoye and Jafarzadeh [19], who found that PEP is
vital pulp than in teeth with necrotic pulp or retreated teeth more common following treatment of teeth with vital pulp.
(Table 2). No such correlation was found 18 h after treatment In contrast, Albashaireh and Alnegrish [20], Mor et al.
(Table 2). The type of endodontic treatment was not found [7] and Mattscheck et al. [21] reported greater incidence of
to be correlated with the frequency of analgesic use or with PEP following treatment of teeth with necrotic pulps. The
the level of pain relief following the use of an analgesic. discrepancy may be due to different criteria used to evaluate
PEP or to different endodontic materials and techniques.
3.4. Effect of Pulp Condition on the Type of PEP: Spontaneous The findings of the present study also contrast with those of
or Stimulated Pain. No statistical relation was found between previous studies that reported statistically significant correla-
the pulp condition and the type of pain (stimulated or tions between the presence of periapical lesions and rates of
spontaneous) 6 or 18 h after treatment (Table 3). flare-ups after root canal treatments that were performed by
students or residents [22, 23]. Treatment by students or resi-
dents may be a reason for the discrepancy here, in addition to
3.5. Effect of Gender on PEP. Gender was significantly asso- the fact that those studies evaluated only patients with flare-
ciated with the intensity of PEP. After treatment, women re- up.
ported a higher mean pain intensity than men, 6 h (2.29 ± The reason for the higher incidence and severity of PEP
1.38 (SD) versus 1.95 ± 1.19 (SD), resp., P < 0.034) and 18 h after treatment of teeth with vital pulp is not completely clear.
(1.97 ± 1.21 (SD) versus 1.68 ± 0.99 (SD), resp., P < 0.041). One possibility is that the injury of periapical vital tissue
during endodontic treatment in teeth with vital pulp pro-
3.6. Effect of Tooth Location on PEP. There was no statistically motes more intensive secretion of inflammatory mediators,
significant correlation between tooth location and the inten- such as prostaglandins, leukotrienes, serotonin, histamine,
sity of PEP, 6 and 18 h after treatment. and bradykinin (all of which are also pain mediators).
Here we reported significantly higher levels of PEP after
4. Discussion initial RCT (of teeth with vital pulp) than after retreatment.
This contrasts with the study conducted by Mattscheck et al.
In the present study the incidence of PEP was high, ranging [21] in which no difference was observed between pain
from 34.6% to 63.8%, depending on the pulp condition. RCT after initial root canal treatment and after retreatment. The
of teeth with vital pulp was associated with a higher incidence difference between these two studies may be attributed to the
and intensity of PEP (6 h after treatment) compared to teeth different populations, culture, and attitude to pain, different
4 International Journal of Dentistry

Table 3: Distribution of type of postoperative pain (PEP) after 6 and 18 hours in relation to the different treatment groups.
6 hours after treatment 18 hours after treatment
Treatment
groups Number of Type of PEP Number of Type of PEP
patients Spontaneous Stimulated patients Spontaneous Stimulated
number (%) number (%) number (%) number (%)
Vital pulp 90 73 (81.1) 17 (18.9) 74 33 (44.6) 41 (55.4)
Necrotic pulp 20 17 (85) 3 (15) 18 6 (33.3) 12 (66.7)
Retreatment 40 32 (80) 8 (20) 37 22 (59.5) 15 (40.5)

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