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Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps
Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps John M. Nusstein, DDS, MS,a and Mike Beck, DDS, MA,b Columbus, Ohio THE OHIO STATE UNIVERSITY
Objective. This retrospective study compared differences in preoperative pain and medication use in patients with moderate to severe pain who sought emergency endodontic care for teeth with irreversible pulpitis and for symptomatic teeth with necrotic pulps. Study design. A total of 323 patients seeking emergency endodontic treatment completed questionnaires regarding their biographical information, pain, pain history, and medications. Teeth were tested for vitality, mobility, percussion, and palpation pain. Lymphadenopathy was also evaluated. Results. Patients with irreversible pulpitis waited significantly (P ⬍ .05) longer before seeking emergency care (9 days vs 4 days) than patients with symptomatic teeth with necrotic pulps. No differences (P ⬎ .05) were found between the groups in terms of analgesic or antibiotic use and pain relief from preoperative narcotic medications. Nonnarcotic analgesics were reported to significantly reduce pain more often in patients with symptomatic teeth with necrotic pulps. There were sex differences in the group of patients with irreversible pulpitis: More women than men were taking analgesic medications and, in the group having symptomatic teeth with necrotic pulps, more men than women reported pain relief from their analgesic medications. Conclusion. Patients with irreversible pulpitis wait longer to seek emergency treatment. A majority (81%-83%) of emergency patients with moderate to severe pain will have taken some type of medication(s) to help control their pain, and more women than men with irreversible pulpitis will take an analgesic. By taking their preoperative medication(s), this group of patients will get relief 62% to 65% of the time; furthermore, more men than women with symptomatic teeth with necrotic pulps will experience pain relief. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:207-14)
Pain has historically been described as an amalgamation of both sensation and reaction. It consists of a physical component—the transmission of impulses from the source through nerves, ganglia, the spinal cord, and finally the brain—and a subjective response to the pain stimulus (ie, subconscious reflex and conscious emotional reactions).1,2 The current definition of pain, as described by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such.”3 Pain is cited as the primary cause for seeking emergency endodontic treatment.4 Segal5 has reported that 66% of patients seeking care in an emergency dental clinic were in pain. Interestingly, 89% of these emergency patients had been in pain for more than 1 week. O’Keefe4 reported that 62% of patients seeking emergency endodontic care were in moderate to severe pain. a
Assistant Professor, Advanced Endodontics. Associate Professor, Department of Oral Biology. Received for publication May 20, 2002; returned for revision Jun 14, 2002; accepted for publication Nov 30, 2002. © 2003, Mosby, Inc. All rights reserved. 1079-2104/2003/$30.00 ⫹ 0 doi:10.1016/S1079-2104(02)91732-4
b
The symptoms of teeth with irreversible pulpitis and necrotic pulps with periapical pathosis have been described by numerous sources.6-9 These descriptions have been presented to help the clinician diagnose the status of the pulp and render proper dental treatment. Seltzer et al10 and others11,12 have shown that the histopathologic status of the pulp in vital teeth cannot be determined by considering only a patient’s pain symptoms. Subjective questioning of the patient about the symptoms, a clinical examination, and pulp testing remain the main diagnostic regimen. Previous studies have evaluated the preoperative factors of pain4,5,12,13 and the use of medications to relieve preoperative pain.12 Further study of these preoperative factors in patients presenting for treatment with moderate to severe pain is warranted. In addition, no study has specifically compared these preoperative factors in relationship to patients diagnosed with irreversible pulpitis and symptomatic teeth with pulpal necrosis. The purpose of this retrospective study was to determine whether there were any differences in the preoperative signs, symptoms, history, or use of medications in patients seeking emergency endodontic care for teeth with irreversible pulpitis or symptomatic teeth with 207
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necrotic pulps and those reporting moderate to severe preoperative pain. MATERIAL AND METHODS Three hundred and twenty-three patients seeking emergency treatment were evaluated for this retrospective study. All patients had participated in studies14-21 conducted at The Ohio State University College of Dentistry with the approval of The Ohio State University Human Subjects Committee. All were in good health, as determined by a written health history and oral questioning, and all signed written consent forms. The preoperative questionnaires used in the 8 studies14-21 were identical. The patients were diagnosed with irreversible pulpitis or symptomatic pulpal necrosis with a periapical radiolucency. Each tooth was tested with Green Endo-Ice (Hygenic Corp, Akron, Ohio) and an electric pulp tester (Analytic Technology Corp, Redmond, Wash) to determine pulpal status. Patients diagnosed with symptomatic pulpal necrosis had no swelling to mild swelling and no evidence of a sinus tract. The preoperative parameters of age, sex, race, weight, and tooth type were recorded for each patient. Patients were asked to rate their current pain on the following 4-point scale: 0, no pain; 1, mild pain (ie, pain that was recognizable but not discomforting); 2, moderate pain (ie, pain that was discomforting but bearable); 3, severe pain (ie, pain that caused considerable discomfort and was difficult to bear). Only patients with moderate to severe pain were included in this study. Patients were also asked to rate any pain they perceived during percussion of the tooth and palpation of the soft tissue overlying the root of the affected tooth. The 4-point scale was also used for these tests. The handles of 2 dental instruments were used to determine the mobility of the tooth. A 4-point scale was used as follows: 0, normal physiologic movement; 1, movement in 1 lateral direction; 2, movement in 2 lateral directions but not depressible in the socket; 3, movement in 2 lateral directions and depressibility within the socket. Periodontal probing was done on all affected teeth to rule out periodontal etiology and possible cracked roots. None of the teeth had gingival or periodontal abscesses. The presence of submandibular lymphadenopathy was evaluated by palpating the submental, submandibular, subdigastric, and superior cervical nodes. Patients were questioned about their preoperative symptom history. Specifically, they were asked to rate their current pain and the number of days they had been in pain. Patients were asked about the medications they had been taking for their chief complaint. They were also asked to list all the medications they had taken or
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were taking for the current problem and if the medications helped in easing their symptoms. The Mann-Whitney test was used to analyze differences between the group of patients with irreversible pulpitis and the group with symptomatic necrotic pulps in terms of the following variables: age, weight, number of days in pain, current pain, current percussion pain, current palpation pain, and mobility rating. The continuous variables of age, weight, and number of days in pain were analyzed nonparametrically because of abnormal distributions and unequal variances. Between-group differences in sex, lymphadenopathy, and the efficacy of the medication in relieving pain were analyzed by using the 2 test. The Fisher exact test was used to assess the between-group difference in ethnicity. Comparisons were considered significant at P ⬍ .05. RESULTS The group with irreversible pulpitis consisted of 133 patients, and the group with symptomatic teeth with necrotic pulps consisted of 190 patients. The distribution of tooth types is found in Table I. The preoperative variables of age, sex, weight, and race for the 2 groups are listed in Table II. Statistical analysis revealed no difference, other than sex, between the 2 groups. The preoperative pain ratings are summarized in Table III. The number of days the patient was in pain before seeking treatment was significantly greater for the group of patients with irreversible pulpitis (9 days) than for the group with symptomatic teeth with necrotic pulps (4 days) (P ⬍ .0001). There was no significant difference in the pain ratings (pain rating at the time of the emergency visit) between the 2 groups (P ⫽ .0550). However, this result did reveal a possible tendency toward a difference in pain ratings between the 2 groups. Multivariate analysis with logistic regression to control for the variables of age, sex, narcotic and nonnarcotic analgesic use revealed no significant difference (P ⫽ .4409) between the 2 groups for initial pain ratings. Approximately 50% of the patients with irreversible pulpitis were in moderate pain and 50% were in severe pain at the time they were seen for emergency endodontic treatment. Within the group of patients with symptomatic teeth with necrotic pulps, 45% reported that they were in moderate pain and 55% reported that they were in severe pain at the time of treatment. There was no significant difference in the percussion pain ratings (P ⫽ .1155) between the groups. A multivariate analysis controlling for age, sex, and narcotic and nonnarcotic analgesic use confirmed this finding (P ⫽ .3541). However, there was a significant difference between the palpation pain ratings at the time of treatment (P ⬍ .0001). Patients with symptomatic teeth with
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Table I. Distribution of tooth types in the groups with irreversible pulpitis (n ⫽ 133) and symptomatic necrosis (n ⫽ 190) Tooth type Maxillary teeth First molar Irreversible pulpitis Symptomatic necrosis Second third molar Irreversible pulpitis Symptomatic necrosis First premolar Irreversible pulpitis Symptomatic necrosis Second premolar Irreversible pulpitis Symptomatic necrosis Anteriors Irreversible pulpitis Symptomatic necrosis
No. (percent)
18 (14%) 22 (12%) 26 (20%) 6 (3%) 12 (9%) 9 (5%) 14 (10%) 8 (4%) 3 (2%) 43 (23%)
Tooth type Mandibular teeth First molar Irreversible pulpitis Symptomatic necrosis Second third molar Irreversible pulpitis Symptomatic necrosis First premolar Irreversible pulpitis Symptomatic necrosis Second premolar Irreversible pulpitis Symptomatic necrosis Anteriors Irreversible pulpitis Symptomatic necrosis
No. (percent)
29 (22%) 49 (26%) 25 (19%) 23 (12%) 0 (0%) 6 (3%) 6 (49%) 12 (6%) 0 (0%) 12 (6%)
Table II. Biographical data of patients with irreversible pulpitis (n ⫽ 933) and symptomatic necrosis (n ⫽ 190) Variable Age* Sex Weight* Race
Irreversible pulpitis
Symptomatic necrosis
P value
31 ⫾ 9.4 74 (56%) women 59 (44%) men 175 ⫾ 50.2 lb 78 white 50 black 5 other
33 ⫾ 13.3 y 75 (39%) women 115 (61%) men 173 ⫾ 40.3 lb 136 white 50 black 4 other
.1442 .0041 .7683 .0509
*Mean ⫾ SD.
Table III. Preoperative pain analysis of groups with irreversible pulpitis and symptomatic necrosis No. of d in pain* Pain rating† Percussion pain rating† Palpation pain rating† Mobility† Lymphadenopathy
Irreversible pulpitis (n ⫽ 133)
Symptomatic necrosis (n ⫽ 190)
P value
8.8 ⫾ 10.2 2.00 ⫾ 1.00 2.00 ⫾ 1.00 0.00 ⫾ 0.00 0.00 ⫾ 0.00 0 (0.0%)
4.4 ⫾ 3.9 3.00 ⫾ 1.00 2.00 ⫾ 1.00 1.00 ⫾ 1.00 1.00 ⫾ 1.00 28 (15%)
⬍.0001 .0550 .1155 ⬍.0001 ⬍.0001 ⬍.0001
*Mean ⫾ SD. † Median ⫾ interquartile range.
necrotic pulps rated palpation pain as being more severe than did those with irreversible pulpitis. The mobility of the affected tooth was also found to be significantly different between the 2 groups (P ⬍ .0001). The symptomatic teeth with necrotic pulps had significantly more mobility than the teeth with irreversible pulpitis. Significantly more patients (P ⫽ .0001) with symptomatic teeth having necrotic pulps than patients with irreversible pulpitis presented with lymphadenopathy.
Table IV summarizes the medication use by patients who sought to control their pain. There were no significant differences (P ⫽ .6200) between the 2 groups in terms of the number of patients taking some type of medication, either an antibiotic or a narcotic or nonnarcotic pain medication, to help control their pain. No significant differences were found between the 2 groups when the types of medication(s) taken were categorized as narcotics (P ⫽ .6299), nonnarcotics (P ⫽ .3193), or
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Table IV. History of use of medications for current pain in groups with irreversible pulpitis and symptomatic necrosis
No medication Medications Narcotic medication* Nonnarcotic pain medication(s)† Antibiotic mediation‡ Did medication help with pain? Did narcotic help with pain? Did nonnarcotic help with pain?§
Irreversible pulpitis (n ⫽ 133)
Symptomatic necrosis (n ⫽ 190)
23 (17%) 110 (83%) 25 (23%) 82 (75%) 7 (6%) Yes—68 (62%) No—42 (38%) Yes—17 (68%) No—8 (32%) Yes—22 (56%) No—28 (44%)
37 (19%) 153 (81%) 31 (20%) 122 (80%) 15 (10%) Yes—99 (65%) No—54 (35%) Yes—23 (74%) No—8 (26%) Yes—70 (61%) No—44 (39%)
P value – .6200 .6299 .3193 .3555 .7467
.6100 .0387
*Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. † Taken with or without an antibiotic or another nonnarcotic analgesic but no narcotic analgesic. ‡ Taken alone or in combination with a narcotic or nonnarcotic analgesic, or both. § Taken alone wihtout an antibiotic or narcotic analgesic.
antibiotics (P ⫽ .3555). With respect to whether the medication(s) they were taking helped control their pain, no significant difference (P ⫽ .7467) was found between the 2 groups. The use of a narcotic medication (alone or in combination with another pain medication or antibiotic, or both) did not create any significant difference in terms of effectiveness in relieving pain between the group with symptomatic necrotic pulps and the group with irreversible pulpitis (P ⫽ .6100). In the majority of cases (both groups), the narcotic medication was reported to be helpful. The use of a nonnarcotic analgesic (without concomitant use of an antibiotic or narcotic analgesic) was reported to be less successful in controlling pain (56% vs 68% in the group with irreversible pulpitis and 61% vs 74% in the group with symptomatic teeth with necrotic pulps) than the use of a narcotic pain medication (Table IV). A significant difference (P ⫽ .0387) in the reported effectiveness of the nonnarcotic analgesics between the 2 groups was found. The patients with symptomatic teeth with necrotic pulps reported more pain relief (61% vs 56%) than the patients with irreversible pulpitis. Table V summarizes the type of medications (analgesic and antibiotics) patients took to help control their pain. Ibuprofen was the nonnarcotic pain medication taken most often. This was followed by acetaminophen and aspirin. Codeine and hydrocodone were the narcotic analgesics taken most often by patients, followed by oxycodone and propoxyphene. Penicillin was the antibiotic taken most often in both groups. Table VI summarizes the sex differences in pain medication use within the group with irreversible pulpitis. Female patients reported taking significantly more analgesic medications (P ⫽ .0228) than did male patients. However, there were no significant differences
(P ⫽ .7036) between the sexes with respect to the type of analgesic medication taken. No significant differences (P ⫽ .4865) were seen in the reported effectiveness of the analgesics between the sexes. Table VII summarizes the sex differences in pain medication usage within the group with symptomatic necrotic pulps. No significant differences (P ⫽ .8205) were found in analgesic medication usage between male and female patients, nor was there any significant difference (P⫽ .7925) in the type of analgesic used by either male or female patients within this group. However, male patients reported significantly (P ⫽ .0254) more pain relief, derived from the analgesic medication(s) they took for their symptomatic teeth with necrotic pulps, than did female patients. DISCUSSION Patients in both groups were in moderate to severe pain when they were seen for treatment (Table III). O’Keefe4 reported that 63% of patients were in moderate to severe pain at the time of emergency endodontic treatment. Dummer et al12 found that 87% of patients with irreversible pulpitis and 100% of patients with symptomatic teeth with necrotic pulps were in moderate to severe pain at the time of treatment. The difference between the current study and previous studies may be related to the inclusion of patients in mild pain in the previous studies and the fact that the current study sampled only patients in moderate to severe pain. In analyzing the biographical data of both groups, no significant differences were found in the variables of age and weight (Table II). Race was of borderline nonsignificance (P ⫽ .0509) between the 2 groups. The effect race may have had on pain ratings in this study is unknown. However, previous studies4,22 have reported
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Table V. History and types of medications used for current pain in groups with irreversible pulpitis and symptomatic necrosis* Irreversible pulpitis (n ⫽ 110)
Symptomatic necrosis (n ⫽ 153)
44 (40%) 31 (28%) 11 (10%) 8 (7%) 8 (7%) 2 (2%)
70 (46%) 32 (21%) 23 (15%) 8 (5%) 8 (5%) 6 (4%)
7 (6%) 12 (11%) 3 (3%) 3 (3%)
11 (7%) 10 (6%) 6 (4%) 4 (3%)
4 (4%) 2 (2%) 0 (0%) 0 (0%) 1 (1%)
7 (5%) 2 (2%) 3 (2%) 1 (1%) 2 (2%)
Nonnarcotic pain medication(s)† Ibuprofen Acetaminophen Aspirin Naproxen Topical anesthetic Other (ketoprofen, ketorolac, Excedrin) Narcotic medication‡ Hydrocodone/acetaminophen Codein/acetaminophen Oxycodone/acetaminophen Propoxyphene Antibiotic§ Penicillin Amoxicillin Erythromycin Clindamycin Others
*Patients may have taken more than 1 nonnarcotic/narcotic analgesic. † Taken alone or in combination with an antibiotic or narcotic analgesic, or both. ‡ Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. § Taken alone or in combination with a narcotic or nonnarcotic analgesic, or both.
Table VI. Sex differences in the use of pain medications within the group with irreversible pulpitis No medications Analgesic medication(s) Narcotic medication* Nonnarcotic pain medication† Did medication help with pain?
Total
Men
Women
P value
23 (23%) 107 (77%) 25 (23%) 82 (77%) Yes—68 (64%) No—39 (36%)
15 (67%) 42 (39%) 9 (31%) 33 (40%) 25 (37%) 17 (44%)
8 (33%) 65 (61%) 16 (69%) 49 (60%) 43 (63%) 22 (56%)
.0228 .7036 .4685
*Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. † Taken with or without an antibiotic or another nonnarcotic analgesic but no narcotic analgesic.
that race had no effect on the reporting of pain. Therefore, for patients in moderate to severe pain, the populations of the 2 groups were similar in regard to these 3 variables. The group with irreversible pulpitis had a similar distribution of men and women, whereas the group with symptomatic necrotic pulps had significantly more men than women (Table II). In general, it has been reported that female patients have lower pain thresholds and are less tolerant of pain.23 Women have also reported greater health care use than men24,25 and use analgesics more frequently.25-27 However, a study of self-reported pain variables such as the number of pain episodes and the average severity of pain revealed no sex differences.28 Because there are differences and similarities in the pain experiences of women and men, the psychological variables and coping strategies of
men and women in pain should be studied further.25 Why the 2 groups of patients in this study exhibited significant sex differences is unclear and warrants further study. Patients in the 2 groups waited a mean of 4 to 9 days before seeking emergency endodontic treatment (Table III). Segal5 reported that 89% of patients waited 1 week or longer before seeking emergency care. Dummer et al12 reported that 54% of patients diagnosed with a symptomatic vital tooth were in pain for more than 3 days, whereas 41% of patients with symptomatic teeth with necrotic pulps waited more than 3 days before seeking care. Baranska-Gachowska and WaszkiewiczGolos13 reported that patients diagnosed with acute pulpitis waited 3 to 14 days before seeking care. The differences in results may be attributable to differences
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Table VII. Sex differences in the use of pain medications in the symptomatic necrotic group No medications Analgesic medication(s) Narcotic medication* Nonnarcotic pain medication† Did medication help with pain?
Total
Men
Women
P value
37 (19%) 153 (81%) 31 (20%) 122 (80%) Yes—99 (65%) No—54 (35%)
23 (62%) 92 (60%) 18 (58%) 74 (61%) 66 (67%) 26 (48%)
14 (38%) 61 (40%) 13 (42%) 48 (39%) 33 (33%) 28 (52%)
.8205 .7925 .0254
*Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. † Taken with or without an antibiotic or another nonnarcotic analgesic but no narcotic analgesic.
in study populations for each study or to the fact that in the current study, only patients reporting moderate to severe pain were analyzed. Patients with irreversible pulpitis waited significantly longer (9 days) to seek emergency endodontic care than patients with symptomatic teeth with necrotic pulps (4 days) (Table III). Although all the patients presented with moderate to severe pain, we can speculate that the course of preoperative pain for patients in the 2 groups may be different. Preoperative pain in patients with irreversible pulpitis may be intermittent, or pain may occur because of hot or cold stimuli, or both. Preoperative pain in symptomatic teeth with necrotic pulps is related to pain periradicularly and may be more of a constant, dull pain. Therefore, patients with irreversible pulpitis may wait until the pain becomes constant or intolerable before seeking treatment. Patients with symptomatic teeth with necrotic pulps may be more likely to seek treatment because the preoperative pain gets progressively worse. Regardless of the differences in the 2 groups, the clinician must realize that over the course of 4 to 9 days, many patients may have not slept, eaten properly, or functioned normally. The end result may be a patient with less tolerance for pain. Percussion of the offending tooth was found to cause moderate pain with no significant difference between the group with irreversible pulpitis and the group with symptomatic teeth with necrotic pulps (Table III). In symptomatic teeth with necrotic pulps, percussion pain is caused by periapical inflammation, and breakdown of the support tissues is caused by the spread of necrosis/ bacterial infection into the periradicular bone. Percussion pain in irreversible pulpitis can be related to the extension of inflammation beyond the apical foramen, even though the pulp remains vital,9,29 or to the fact that because the pulp is involved with inflammation, movement due to percussion causes pain. In the group of patients with irreversible pulpitis, no distinction was made between patients with a radiographically normal periapex and those with acute apical periodontitis (widened periodontal ligament space). Although some cli-
nicians may use the distinction between the 2 groups to determine the minimal emergency procedures necessary to relieve pain, our treatment would be complete pulpal debridement regardless of the initial distinction. Therefore, the periradicular diagnosis was not recorded for patients with vital teeth with irreversible pulpitis. Percussion testing appears to be an appropriate diagnostic aid for either teeth with irreversible pulpitis or symptomatic teeth with necrotic pulps. Pain on palpation, lymphadenopathy, and mobility were found only in symptomatic teeth with necrotic pulps. None of these conditions were found in teeth with irreversible pulpitis (Table III). All of these conditions are indicators of periradicular inflammation associated with a necrotic pulp and would not be present in a tooth with irreversible pulpitis. The use of analgesic and antibiotic medications to control pain was found in both groups of patients (Table IV). Eighty-three percent of patients with irreversible pulpitis and 81% of patients with symptomatic teeth with necrotic pulps took some type of medication for their pain. Therefore, the majority of patients in moderate to severe pain are trying to control their pain before they seek endodontic treatment. Walton and Fouad30 reported that only 18% of patients reported taking an analgesic medication for preoperative pain. The difference between our results and the study by Walton and Fouad30 could be attributable to the fact that all of the patients in our study had moderate to severe pain, whereas Walton and Fouad30 included symptom-free patients in their study. When patients were questioned whether the medications they took helped control their pain (Table IV), those with irreversible pulpitis and those with symptomatic necrotic pulps reported relief 62% and 65% of the time, respectively. Dummer et al12 reported that 51% of patients with irreversible pulpitis and 53% of patients with symptomatic teeth with necrotic pulps failed to get relief from analgesic medications. However, they did not describe the types of medications that were taken and not all patients were in moderate to severe pain. For the patients taking narcotic analgesics,
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when they were asked if the pain was controlled by their medications, there was no difference found between the groups (Table IV). Narcotic analgesics appeared to be helpful in a majority (68%-74%) of the patients who took them. Nonnarcotic analgesics were reported to be helpful by 56% to 61% of patients (Table IV). It should be noted that the number, strength, and dosing schedule for the medications the patients reported taking were not recorded. A significant difference (P ⫽ .0387) was noted between the 2 groups, in that patients having symptomatic teeth with necrotic pulps reported more relief with the nonnarcotic analgesics. This may be attributable to the nature of the symptoms between the 2 groups, where symptomatic teeth with necrotic pulps have a constant ache and teeth with irreversible pulpitis may have more sporadic pain or pain that is brought on by stimulation (ie, cold or hot fluids or air). In previous studies by Gallatin et al19 and Nagle et 21 al, the majority of patients with untreated irreversible pulpitis had significant pain and required analgesics (both ibuprofen and narcotics) to manage their pain. Nagle et al21 also showed that the administration of penicillin did not significantly reduce pain or the number of analgesic medications taken by patients with irreversible pulpitis. The pain of irreversible pulpitis is difficult to manage with just analgesic medications, and penicillin has no effect in reducing this pain. Therefore, patients in the current study would not be expected to have complete pain relief using only preoperative medications. Removal of the inflamed pulpal tissue or the use of an intraosseous injection of Depo-Medrol to temporarily alleviate symptoms19 are the most predictable treatments to relieve the pain of irreversible pulpitis. However, no study has described the clinical course of pain and analgesic use in patients with untreated (ie, no endodontic debridement) symptomatic teeth with necrotic pulps. Generally, the findings in studies of postoperative pain, after endodontic debridement of symptomatic teeth with necrotic pulps, reveal a reduction in moderate to severe pain in the majority of patients after 3 days.14-16,30,31 During the 3 days, the majority of patients had significant postoperative pain and required analgesics (both ibuprofen and narcotics) to manage their pain.14-16 Because the resolution of symptoms may take 3 days in treated patients with symptomatic teeth having necrotic pulps, patients in the current study would not be expected to have complete pain relief using the preoperative medications they took. A great variety of medications were taken by patients in both groups in an attempt to control their preoperative pain (Table V). These were narcotics, antibiotics,
nonsteroidal anti-inflammatories, acetaminophen, and over-the-counter topical anesthetics, in addition to any number of combinations of these. Ibuprofen was the most popular nonsteroidal anti-inflammatory medication used in either group. The use of ibuprofen may be related to effective product advertising and marketing. Less than a quarter of the patients (irreversible pulpitis, 23%; symptomatic teeth with necrotic pulps, 20%) reported taking some form of narcotic-containing pain reliever. This is most likely because of the unavailability of these types of medications in over-the-counter form. We found that patients received their medications from various sources, including hospital emergency rooms, friends, relatives, and drug stores, or had medications remaining from previous unrelated therapies. Within the group with irreversible pulpitis, significantly more women took an analgesic medication than men (Table VI). This difference was not significant in the group with symptomatic teeth with necrotic pulps (Table VII). There were no differences found between the sexes for narcotic or nonnarcotic analgesic usage within either group. These results parallel the findings reported by Eggen26 and Antonov and Isacson.27 In both of those studies, to control pain, women used analgesics more frequently than did men. Thus, women may resort to an analgesic medication more frequently than do men to help control the pain of irreversible pulpitis. However, in symptomatic teeth with necrotic pulps, men may report more relief of their moderate to severe pain after taking an analgesic medication (Table VII). CONCLUSION In this study of patients with moderate to severe pain seeking emergency endodontic treatment, we found that patients with irreversible pulpitis will wait longer (9 days) than those with a symptomatic tooth with a necrotic pulp (4 days) before seeking emergency treatment. A majority (81%-83%) of these patients will have taken some type(s) of medication (narcotic, 20%23%; nonnarcotic, 75%-80%; antibiotic, 6%-10%) to help control their pain. The patient’s pain will be relieved approximately 62% to 65% of the time with the medication(s). Men will have more pain relief than will women in symptomatic teeth with necrotic pulps, but women will take an analgesic medication more often than men in cases of irreversible pulpitis. REFERENCES 1. Topazian RG. Pain thresholds and factors which modify them. Oral Surg Oral Med Oral Pathol 1957;10:1192-1203. 2. Hardy JD. The nature of pain. J Chronic Dis 1956;4:22-51. 3. IASP Subcommittee on Taxonomy. Pain terms: a list with definitions and notes on usage. Pain 1979;6:249-52. 4. O’Keefe EM. Pain in endodontic therapy: preliminary study. J Endod 1976;2:315-9.
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5. Segal H. Duration and type of emergency patients. Gen Dent 1984;32:507-9. 6. Cohen S, Liewehr F. Diagnostic procedures. In: Cohen S, Burns R, editors. Pathways of the pulp. 8th ed. St Louis: Mosby, Inc; 2002. p. 26-9. 7. Walton R, Torabinejad M. Diagnosis and treatment planning. In: Walton R, Torabinejad M, editors. Principles and practice of endodontics. 2nd ed. Philadelphia: W. B. Saunders; 1996. p. 54-67. 8. Smulson M, Sieraski S. Histophysiology and diseases of the dental pulp. In: Weine F, editor. Endodontic therapy. 5th ed. St Louis: Mosby; 1989. p. 140-62. 9. Cunningham CJ, Mullany TP. Pain control in endodontics. Dent Clin North Am 1992;36:393-408. 10. Seltzer S, Bender IB, Zionitz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:846-71,969-77. 11. Tyldesley WR, Mumford JM. Dental pain and the histological condition of the pulp. Dent Pract Dent Rec 1970;10:333-6. 12. Dummer PM, Hicks R, Huws D. Clinical signs and symptoms in pulp disease. Int Endod J 1980;13:27-35. 13. Baranska-Gachowska M, Waszkiewicz-Golos H. Diagnostic significance of clinical manifestations in evaluation of the stage of dental pulp in the light of histological examinations. Pol Med J 1969;8:725-35. 14. Houck V, Reader A, Beck M, Nist R, Weaver J. Effect of trephination on postoperative pain and swelling in symptomatic necrotic teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:507-13. 15. Nist E, Reader A, Beck M, Weaver J. An evaluation of apical trephination on postoperative endodontic pain in symptomatic necrotic teeth. J Endod 2001;27:415-23. 16. Henry M, Reader A, Beck M, Gallatin E. Effect of penicillin on postoperative pain and swelling in symptomatic, necrotic teeth. J Endod 2001;27:117-23. 17. Bramy E, Reader A, Nist R, Beck M, Weaver J. The intraosseous injection of Depo-Medrol on postoperative endodontic pain in symptomatic necrotic teeth [abstract]. J Endod 1999;25:289. 18. Claffey D, Reader A, Beck M, Weaver J. The effect of an oral dose regimen of methylprednisolone on postoperative endodontic pain in symptomatic, necrotic teeth [abstract]. J Endod 2001; 27:223. 19. Gallatin E, Reader A, Nist R, Beck M. Pain reduction in untreated irreversible pulpitis using an intraosseous injection of Depo-Medrol. J Endod 2000;26:633-8. 20. Isett J, Gallatin E, Reader A, Beck M, Padget D. Effect of
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29. 30.
31.
intraosseous injection of Depo-Medrol on pulpal concentrations of PGE2 and IL-8 in untreated irreversible pulpitis [abstract]. J Endod 2000;26:542. Nagle D, Reader A, Beck M, Weaver J. Effect of systemic penicillin on pain in untreated irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:636-40. Mulhern J, Patterson S, Newton C, Ringel A. Incidence of postoperative pain after one-appointment endodontic treatment of asymptomatic pulpal necrosis in single-rooted teeth. J Endod 1982;8:370-5. Keogh E, Hatton K, Ellery D. Avoidance versus focused attention and the perception of pain: differential effects for men and women. Pain 2000;85:225-30. Krasnik A, Hansen E, Keiding N, Sawtiz A. Determinants of general practice utilization in Denmark. Dan Med Bull 1997;44: 542-6. Fillingham R, Edwards R, Powell T. The relationship of sex and clinical pain to experimental pain responses. Pain 1999;83:41925. Eggen AE. The Tromso study: frequency and predicting factors of analgesic drug use in a free-living population (12-56 years). J Clin Epidemiol 1993;46:1297-1304. Antonov K, Isacson D. Headache and analgesic use in Sweden. Headache 1998;38:97-104. Lester N, Lefebvre JC, Keefe FJ. Pain in young adults: I. Relationship to gender and family pain history. Clin J Pain 1994;10: 282-9. Tronstad L. The apical periodontium: In: Clinical endodontics. New York: Thieme Medical Publishers; 1991. p. 33-5. Walton R, Fouad A. Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endod 1992;18:172-7. Fouad A, Rivera E, Walton R. Penicillin as a supplement in resolving the localized acute apical abscess. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:590-5.
Reprint requests: John Nusstein, DDS, MS Advanced Endodontics College of Dentistry The Ohio State University 305 W 12th Ave Box 182357 Columbus, OH 43218-2357 [email protected]
Objective. This retrospective study compared differences in preoperative pain and medication use in patients with moderate to severe pain who sought emergency endodontic care for teeth with irreversible pulpitis and for symptomatic teeth with necrotic pulps. Study design. A total of 323 patients seeking emergency endodontic treatment completed questionnaires regarding their biographical information, pain, pain history, and medications. Teeth were tested for vitality, mobility, percussion, and palpation pain. Lymphadenopathy was also evaluated. Results. Patients with irreversible pulpitis waited significantly (P ⬍ .05) longer before seeking emergency care (9 days vs 4 days) than patients with symptomatic teeth with necrotic pulps. No differences (P ⬎ .05) were found between the groups in terms of analgesic or antibiotic use and pain relief from preoperative narcotic medications. Nonnarcotic analgesics were reported to significantly reduce pain more often in patients with symptomatic teeth with necrotic pulps. There were sex differences in the group of patients with irreversible pulpitis: More women than men were taking analgesic medications and, in the group having symptomatic teeth with necrotic pulps, more men than women reported pain relief from their analgesic medications. Conclusion. Patients with irreversible pulpitis wait longer to seek emergency treatment. A majority (81%-83%) of emergency patients with moderate to severe pain will have taken some type of medication(s) to help control their pain, and more women than men with irreversible pulpitis will take an analgesic. By taking their preoperative medication(s), this group of patients will get relief 62% to 65% of the time; furthermore, more men than women with symptomatic teeth with necrotic pulps will experience pain relief. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:207-14)
Pain has historically been described as an amalgamation of both sensation and reaction. It consists of a physical component—the transmission of impulses from the source through nerves, ganglia, the spinal cord, and finally the brain—and a subjective response to the pain stimulus (ie, subconscious reflex and conscious emotional reactions).1,2 The current definition of pain, as described by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such.”3 Pain is cited as the primary cause for seeking emergency endodontic treatment.4 Segal5 has reported that 66% of patients seeking care in an emergency dental clinic were in pain. Interestingly, 89% of these emergency patients had been in pain for more than 1 week. O’Keefe4 reported that 62% of patients seeking emergency endodontic care were in moderate to severe pain. a
Assistant Professor, Advanced Endodontics. Associate Professor, Department of Oral Biology. Received for publication May 20, 2002; returned for revision Jun 14, 2002; accepted for publication Nov 30, 2002. © 2003, Mosby, Inc. All rights reserved. 1079-2104/2003/$30.00 ⫹ 0 doi:10.1016/S1079-2104(02)91732-4
b
The symptoms of teeth with irreversible pulpitis and necrotic pulps with periapical pathosis have been described by numerous sources.6-9 These descriptions have been presented to help the clinician diagnose the status of the pulp and render proper dental treatment. Seltzer et al10 and others11,12 have shown that the histopathologic status of the pulp in vital teeth cannot be determined by considering only a patient’s pain symptoms. Subjective questioning of the patient about the symptoms, a clinical examination, and pulp testing remain the main diagnostic regimen. Previous studies have evaluated the preoperative factors of pain4,5,12,13 and the use of medications to relieve preoperative pain.12 Further study of these preoperative factors in patients presenting for treatment with moderate to severe pain is warranted. In addition, no study has specifically compared these preoperative factors in relationship to patients diagnosed with irreversible pulpitis and symptomatic teeth with pulpal necrosis. The purpose of this retrospective study was to determine whether there were any differences in the preoperative signs, symptoms, history, or use of medications in patients seeking emergency endodontic care for teeth with irreversible pulpitis or symptomatic teeth with 207
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necrotic pulps and those reporting moderate to severe preoperative pain. MATERIAL AND METHODS Three hundred and twenty-three patients seeking emergency treatment were evaluated for this retrospective study. All patients had participated in studies14-21 conducted at The Ohio State University College of Dentistry with the approval of The Ohio State University Human Subjects Committee. All were in good health, as determined by a written health history and oral questioning, and all signed written consent forms. The preoperative questionnaires used in the 8 studies14-21 were identical. The patients were diagnosed with irreversible pulpitis or symptomatic pulpal necrosis with a periapical radiolucency. Each tooth was tested with Green Endo-Ice (Hygenic Corp, Akron, Ohio) and an electric pulp tester (Analytic Technology Corp, Redmond, Wash) to determine pulpal status. Patients diagnosed with symptomatic pulpal necrosis had no swelling to mild swelling and no evidence of a sinus tract. The preoperative parameters of age, sex, race, weight, and tooth type were recorded for each patient. Patients were asked to rate their current pain on the following 4-point scale: 0, no pain; 1, mild pain (ie, pain that was recognizable but not discomforting); 2, moderate pain (ie, pain that was discomforting but bearable); 3, severe pain (ie, pain that caused considerable discomfort and was difficult to bear). Only patients with moderate to severe pain were included in this study. Patients were also asked to rate any pain they perceived during percussion of the tooth and palpation of the soft tissue overlying the root of the affected tooth. The 4-point scale was also used for these tests. The handles of 2 dental instruments were used to determine the mobility of the tooth. A 4-point scale was used as follows: 0, normal physiologic movement; 1, movement in 1 lateral direction; 2, movement in 2 lateral directions but not depressible in the socket; 3, movement in 2 lateral directions and depressibility within the socket. Periodontal probing was done on all affected teeth to rule out periodontal etiology and possible cracked roots. None of the teeth had gingival or periodontal abscesses. The presence of submandibular lymphadenopathy was evaluated by palpating the submental, submandibular, subdigastric, and superior cervical nodes. Patients were questioned about their preoperative symptom history. Specifically, they were asked to rate their current pain and the number of days they had been in pain. Patients were asked about the medications they had been taking for their chief complaint. They were also asked to list all the medications they had taken or
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY August 2003
were taking for the current problem and if the medications helped in easing their symptoms. The Mann-Whitney test was used to analyze differences between the group of patients with irreversible pulpitis and the group with symptomatic necrotic pulps in terms of the following variables: age, weight, number of days in pain, current pain, current percussion pain, current palpation pain, and mobility rating. The continuous variables of age, weight, and number of days in pain were analyzed nonparametrically because of abnormal distributions and unequal variances. Between-group differences in sex, lymphadenopathy, and the efficacy of the medication in relieving pain were analyzed by using the 2 test. The Fisher exact test was used to assess the between-group difference in ethnicity. Comparisons were considered significant at P ⬍ .05. RESULTS The group with irreversible pulpitis consisted of 133 patients, and the group with symptomatic teeth with necrotic pulps consisted of 190 patients. The distribution of tooth types is found in Table I. The preoperative variables of age, sex, weight, and race for the 2 groups are listed in Table II. Statistical analysis revealed no difference, other than sex, between the 2 groups. The preoperative pain ratings are summarized in Table III. The number of days the patient was in pain before seeking treatment was significantly greater for the group of patients with irreversible pulpitis (9 days) than for the group with symptomatic teeth with necrotic pulps (4 days) (P ⬍ .0001). There was no significant difference in the pain ratings (pain rating at the time of the emergency visit) between the 2 groups (P ⫽ .0550). However, this result did reveal a possible tendency toward a difference in pain ratings between the 2 groups. Multivariate analysis with logistic regression to control for the variables of age, sex, narcotic and nonnarcotic analgesic use revealed no significant difference (P ⫽ .4409) between the 2 groups for initial pain ratings. Approximately 50% of the patients with irreversible pulpitis were in moderate pain and 50% were in severe pain at the time they were seen for emergency endodontic treatment. Within the group of patients with symptomatic teeth with necrotic pulps, 45% reported that they were in moderate pain and 55% reported that they were in severe pain at the time of treatment. There was no significant difference in the percussion pain ratings (P ⫽ .1155) between the groups. A multivariate analysis controlling for age, sex, and narcotic and nonnarcotic analgesic use confirmed this finding (P ⫽ .3541). However, there was a significant difference between the palpation pain ratings at the time of treatment (P ⬍ .0001). Patients with symptomatic teeth with
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Table I. Distribution of tooth types in the groups with irreversible pulpitis (n ⫽ 133) and symptomatic necrosis (n ⫽ 190) Tooth type Maxillary teeth First molar Irreversible pulpitis Symptomatic necrosis Second third molar Irreversible pulpitis Symptomatic necrosis First premolar Irreversible pulpitis Symptomatic necrosis Second premolar Irreversible pulpitis Symptomatic necrosis Anteriors Irreversible pulpitis Symptomatic necrosis
No. (percent)
18 (14%) 22 (12%) 26 (20%) 6 (3%) 12 (9%) 9 (5%) 14 (10%) 8 (4%) 3 (2%) 43 (23%)
Tooth type Mandibular teeth First molar Irreversible pulpitis Symptomatic necrosis Second third molar Irreversible pulpitis Symptomatic necrosis First premolar Irreversible pulpitis Symptomatic necrosis Second premolar Irreversible pulpitis Symptomatic necrosis Anteriors Irreversible pulpitis Symptomatic necrosis
No. (percent)
29 (22%) 49 (26%) 25 (19%) 23 (12%) 0 (0%) 6 (3%) 6 (49%) 12 (6%) 0 (0%) 12 (6%)
Table II. Biographical data of patients with irreversible pulpitis (n ⫽ 933) and symptomatic necrosis (n ⫽ 190) Variable Age* Sex Weight* Race
Irreversible pulpitis
Symptomatic necrosis
P value
31 ⫾ 9.4 74 (56%) women 59 (44%) men 175 ⫾ 50.2 lb 78 white 50 black 5 other
33 ⫾ 13.3 y 75 (39%) women 115 (61%) men 173 ⫾ 40.3 lb 136 white 50 black 4 other
.1442 .0041 .7683 .0509
*Mean ⫾ SD.
Table III. Preoperative pain analysis of groups with irreversible pulpitis and symptomatic necrosis No. of d in pain* Pain rating† Percussion pain rating† Palpation pain rating† Mobility† Lymphadenopathy
Irreversible pulpitis (n ⫽ 133)
Symptomatic necrosis (n ⫽ 190)
P value
8.8 ⫾ 10.2 2.00 ⫾ 1.00 2.00 ⫾ 1.00 0.00 ⫾ 0.00 0.00 ⫾ 0.00 0 (0.0%)
4.4 ⫾ 3.9 3.00 ⫾ 1.00 2.00 ⫾ 1.00 1.00 ⫾ 1.00 1.00 ⫾ 1.00 28 (15%)
⬍.0001 .0550 .1155 ⬍.0001 ⬍.0001 ⬍.0001
*Mean ⫾ SD. † Median ⫾ interquartile range.
necrotic pulps rated palpation pain as being more severe than did those with irreversible pulpitis. The mobility of the affected tooth was also found to be significantly different between the 2 groups (P ⬍ .0001). The symptomatic teeth with necrotic pulps had significantly more mobility than the teeth with irreversible pulpitis. Significantly more patients (P ⫽ .0001) with symptomatic teeth having necrotic pulps than patients with irreversible pulpitis presented with lymphadenopathy.
Table IV summarizes the medication use by patients who sought to control their pain. There were no significant differences (P ⫽ .6200) between the 2 groups in terms of the number of patients taking some type of medication, either an antibiotic or a narcotic or nonnarcotic pain medication, to help control their pain. No significant differences were found between the 2 groups when the types of medication(s) taken were categorized as narcotics (P ⫽ .6299), nonnarcotics (P ⫽ .3193), or
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Table IV. History of use of medications for current pain in groups with irreversible pulpitis and symptomatic necrosis
No medication Medications Narcotic medication* Nonnarcotic pain medication(s)† Antibiotic mediation‡ Did medication help with pain? Did narcotic help with pain? Did nonnarcotic help with pain?§
Irreversible pulpitis (n ⫽ 133)
Symptomatic necrosis (n ⫽ 190)
23 (17%) 110 (83%) 25 (23%) 82 (75%) 7 (6%) Yes—68 (62%) No—42 (38%) Yes—17 (68%) No—8 (32%) Yes—22 (56%) No—28 (44%)
37 (19%) 153 (81%) 31 (20%) 122 (80%) 15 (10%) Yes—99 (65%) No—54 (35%) Yes—23 (74%) No—8 (26%) Yes—70 (61%) No—44 (39%)
P value – .6200 .6299 .3193 .3555 .7467
.6100 .0387
*Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. † Taken with or without an antibiotic or another nonnarcotic analgesic but no narcotic analgesic. ‡ Taken alone or in combination with a narcotic or nonnarcotic analgesic, or both. § Taken alone wihtout an antibiotic or narcotic analgesic.
antibiotics (P ⫽ .3555). With respect to whether the medication(s) they were taking helped control their pain, no significant difference (P ⫽ .7467) was found between the 2 groups. The use of a narcotic medication (alone or in combination with another pain medication or antibiotic, or both) did not create any significant difference in terms of effectiveness in relieving pain between the group with symptomatic necrotic pulps and the group with irreversible pulpitis (P ⫽ .6100). In the majority of cases (both groups), the narcotic medication was reported to be helpful. The use of a nonnarcotic analgesic (without concomitant use of an antibiotic or narcotic analgesic) was reported to be less successful in controlling pain (56% vs 68% in the group with irreversible pulpitis and 61% vs 74% in the group with symptomatic teeth with necrotic pulps) than the use of a narcotic pain medication (Table IV). A significant difference (P ⫽ .0387) in the reported effectiveness of the nonnarcotic analgesics between the 2 groups was found. The patients with symptomatic teeth with necrotic pulps reported more pain relief (61% vs 56%) than the patients with irreversible pulpitis. Table V summarizes the type of medications (analgesic and antibiotics) patients took to help control their pain. Ibuprofen was the nonnarcotic pain medication taken most often. This was followed by acetaminophen and aspirin. Codeine and hydrocodone were the narcotic analgesics taken most often by patients, followed by oxycodone and propoxyphene. Penicillin was the antibiotic taken most often in both groups. Table VI summarizes the sex differences in pain medication use within the group with irreversible pulpitis. Female patients reported taking significantly more analgesic medications (P ⫽ .0228) than did male patients. However, there were no significant differences
(P ⫽ .7036) between the sexes with respect to the type of analgesic medication taken. No significant differences (P ⫽ .4865) were seen in the reported effectiveness of the analgesics between the sexes. Table VII summarizes the sex differences in pain medication usage within the group with symptomatic necrotic pulps. No significant differences (P ⫽ .8205) were found in analgesic medication usage between male and female patients, nor was there any significant difference (P⫽ .7925) in the type of analgesic used by either male or female patients within this group. However, male patients reported significantly (P ⫽ .0254) more pain relief, derived from the analgesic medication(s) they took for their symptomatic teeth with necrotic pulps, than did female patients. DISCUSSION Patients in both groups were in moderate to severe pain when they were seen for treatment (Table III). O’Keefe4 reported that 63% of patients were in moderate to severe pain at the time of emergency endodontic treatment. Dummer et al12 found that 87% of patients with irreversible pulpitis and 100% of patients with symptomatic teeth with necrotic pulps were in moderate to severe pain at the time of treatment. The difference between the current study and previous studies may be related to the inclusion of patients in mild pain in the previous studies and the fact that the current study sampled only patients in moderate to severe pain. In analyzing the biographical data of both groups, no significant differences were found in the variables of age and weight (Table II). Race was of borderline nonsignificance (P ⫽ .0509) between the 2 groups. The effect race may have had on pain ratings in this study is unknown. However, previous studies4,22 have reported
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Table V. History and types of medications used for current pain in groups with irreversible pulpitis and symptomatic necrosis* Irreversible pulpitis (n ⫽ 110)
Symptomatic necrosis (n ⫽ 153)
44 (40%) 31 (28%) 11 (10%) 8 (7%) 8 (7%) 2 (2%)
70 (46%) 32 (21%) 23 (15%) 8 (5%) 8 (5%) 6 (4%)
7 (6%) 12 (11%) 3 (3%) 3 (3%)
11 (7%) 10 (6%) 6 (4%) 4 (3%)
4 (4%) 2 (2%) 0 (0%) 0 (0%) 1 (1%)
7 (5%) 2 (2%) 3 (2%) 1 (1%) 2 (2%)
Nonnarcotic pain medication(s)† Ibuprofen Acetaminophen Aspirin Naproxen Topical anesthetic Other (ketoprofen, ketorolac, Excedrin) Narcotic medication‡ Hydrocodone/acetaminophen Codein/acetaminophen Oxycodone/acetaminophen Propoxyphene Antibiotic§ Penicillin Amoxicillin Erythromycin Clindamycin Others
*Patients may have taken more than 1 nonnarcotic/narcotic analgesic. † Taken alone or in combination with an antibiotic or narcotic analgesic, or both. ‡ Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. § Taken alone or in combination with a narcotic or nonnarcotic analgesic, or both.
Table VI. Sex differences in the use of pain medications within the group with irreversible pulpitis No medications Analgesic medication(s) Narcotic medication* Nonnarcotic pain medication† Did medication help with pain?
Total
Men
Women
P value
23 (23%) 107 (77%) 25 (23%) 82 (77%) Yes—68 (64%) No—39 (36%)
15 (67%) 42 (39%) 9 (31%) 33 (40%) 25 (37%) 17 (44%)
8 (33%) 65 (61%) 16 (69%) 49 (60%) 43 (63%) 22 (56%)
.0228 .7036 .4685
*Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. † Taken with or without an antibiotic or another nonnarcotic analgesic but no narcotic analgesic.
that race had no effect on the reporting of pain. Therefore, for patients in moderate to severe pain, the populations of the 2 groups were similar in regard to these 3 variables. The group with irreversible pulpitis had a similar distribution of men and women, whereas the group with symptomatic necrotic pulps had significantly more men than women (Table II). In general, it has been reported that female patients have lower pain thresholds and are less tolerant of pain.23 Women have also reported greater health care use than men24,25 and use analgesics more frequently.25-27 However, a study of self-reported pain variables such as the number of pain episodes and the average severity of pain revealed no sex differences.28 Because there are differences and similarities in the pain experiences of women and men, the psychological variables and coping strategies of
men and women in pain should be studied further.25 Why the 2 groups of patients in this study exhibited significant sex differences is unclear and warrants further study. Patients in the 2 groups waited a mean of 4 to 9 days before seeking emergency endodontic treatment (Table III). Segal5 reported that 89% of patients waited 1 week or longer before seeking emergency care. Dummer et al12 reported that 54% of patients diagnosed with a symptomatic vital tooth were in pain for more than 3 days, whereas 41% of patients with symptomatic teeth with necrotic pulps waited more than 3 days before seeking care. Baranska-Gachowska and WaszkiewiczGolos13 reported that patients diagnosed with acute pulpitis waited 3 to 14 days before seeking care. The differences in results may be attributable to differences
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Table VII. Sex differences in the use of pain medications in the symptomatic necrotic group No medications Analgesic medication(s) Narcotic medication* Nonnarcotic pain medication† Did medication help with pain?
Total
Men
Women
P value
37 (19%) 153 (81%) 31 (20%) 122 (80%) Yes—99 (65%) No—54 (35%)
23 (62%) 92 (60%) 18 (58%) 74 (61%) 66 (67%) 26 (48%)
14 (38%) 61 (40%) 13 (42%) 48 (39%) 33 (33%) 28 (52%)
.8205 .7925 .0254
*Taken alone or in combination with an antibiotic or nonnarcotic analgesic, or both. † Taken with or without an antibiotic or another nonnarcotic analgesic but no narcotic analgesic.
in study populations for each study or to the fact that in the current study, only patients reporting moderate to severe pain were analyzed. Patients with irreversible pulpitis waited significantly longer (9 days) to seek emergency endodontic care than patients with symptomatic teeth with necrotic pulps (4 days) (Table III). Although all the patients presented with moderate to severe pain, we can speculate that the course of preoperative pain for patients in the 2 groups may be different. Preoperative pain in patients with irreversible pulpitis may be intermittent, or pain may occur because of hot or cold stimuli, or both. Preoperative pain in symptomatic teeth with necrotic pulps is related to pain periradicularly and may be more of a constant, dull pain. Therefore, patients with irreversible pulpitis may wait until the pain becomes constant or intolerable before seeking treatment. Patients with symptomatic teeth with necrotic pulps may be more likely to seek treatment because the preoperative pain gets progressively worse. Regardless of the differences in the 2 groups, the clinician must realize that over the course of 4 to 9 days, many patients may have not slept, eaten properly, or functioned normally. The end result may be a patient with less tolerance for pain. Percussion of the offending tooth was found to cause moderate pain with no significant difference between the group with irreversible pulpitis and the group with symptomatic teeth with necrotic pulps (Table III). In symptomatic teeth with necrotic pulps, percussion pain is caused by periapical inflammation, and breakdown of the support tissues is caused by the spread of necrosis/ bacterial infection into the periradicular bone. Percussion pain in irreversible pulpitis can be related to the extension of inflammation beyond the apical foramen, even though the pulp remains vital,9,29 or to the fact that because the pulp is involved with inflammation, movement due to percussion causes pain. In the group of patients with irreversible pulpitis, no distinction was made between patients with a radiographically normal periapex and those with acute apical periodontitis (widened periodontal ligament space). Although some cli-
nicians may use the distinction between the 2 groups to determine the minimal emergency procedures necessary to relieve pain, our treatment would be complete pulpal debridement regardless of the initial distinction. Therefore, the periradicular diagnosis was not recorded for patients with vital teeth with irreversible pulpitis. Percussion testing appears to be an appropriate diagnostic aid for either teeth with irreversible pulpitis or symptomatic teeth with necrotic pulps. Pain on palpation, lymphadenopathy, and mobility were found only in symptomatic teeth with necrotic pulps. None of these conditions were found in teeth with irreversible pulpitis (Table III). All of these conditions are indicators of periradicular inflammation associated with a necrotic pulp and would not be present in a tooth with irreversible pulpitis. The use of analgesic and antibiotic medications to control pain was found in both groups of patients (Table IV). Eighty-three percent of patients with irreversible pulpitis and 81% of patients with symptomatic teeth with necrotic pulps took some type of medication for their pain. Therefore, the majority of patients in moderate to severe pain are trying to control their pain before they seek endodontic treatment. Walton and Fouad30 reported that only 18% of patients reported taking an analgesic medication for preoperative pain. The difference between our results and the study by Walton and Fouad30 could be attributable to the fact that all of the patients in our study had moderate to severe pain, whereas Walton and Fouad30 included symptom-free patients in their study. When patients were questioned whether the medications they took helped control their pain (Table IV), those with irreversible pulpitis and those with symptomatic necrotic pulps reported relief 62% and 65% of the time, respectively. Dummer et al12 reported that 51% of patients with irreversible pulpitis and 53% of patients with symptomatic teeth with necrotic pulps failed to get relief from analgesic medications. However, they did not describe the types of medications that were taken and not all patients were in moderate to severe pain. For the patients taking narcotic analgesics,
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when they were asked if the pain was controlled by their medications, there was no difference found between the groups (Table IV). Narcotic analgesics appeared to be helpful in a majority (68%-74%) of the patients who took them. Nonnarcotic analgesics were reported to be helpful by 56% to 61% of patients (Table IV). It should be noted that the number, strength, and dosing schedule for the medications the patients reported taking were not recorded. A significant difference (P ⫽ .0387) was noted between the 2 groups, in that patients having symptomatic teeth with necrotic pulps reported more relief with the nonnarcotic analgesics. This may be attributable to the nature of the symptoms between the 2 groups, where symptomatic teeth with necrotic pulps have a constant ache and teeth with irreversible pulpitis may have more sporadic pain or pain that is brought on by stimulation (ie, cold or hot fluids or air). In previous studies by Gallatin et al19 and Nagle et 21 al, the majority of patients with untreated irreversible pulpitis had significant pain and required analgesics (both ibuprofen and narcotics) to manage their pain. Nagle et al21 also showed that the administration of penicillin did not significantly reduce pain or the number of analgesic medications taken by patients with irreversible pulpitis. The pain of irreversible pulpitis is difficult to manage with just analgesic medications, and penicillin has no effect in reducing this pain. Therefore, patients in the current study would not be expected to have complete pain relief using only preoperative medications. Removal of the inflamed pulpal tissue or the use of an intraosseous injection of Depo-Medrol to temporarily alleviate symptoms19 are the most predictable treatments to relieve the pain of irreversible pulpitis. However, no study has described the clinical course of pain and analgesic use in patients with untreated (ie, no endodontic debridement) symptomatic teeth with necrotic pulps. Generally, the findings in studies of postoperative pain, after endodontic debridement of symptomatic teeth with necrotic pulps, reveal a reduction in moderate to severe pain in the majority of patients after 3 days.14-16,30,31 During the 3 days, the majority of patients had significant postoperative pain and required analgesics (both ibuprofen and narcotics) to manage their pain.14-16 Because the resolution of symptoms may take 3 days in treated patients with symptomatic teeth having necrotic pulps, patients in the current study would not be expected to have complete pain relief using the preoperative medications they took. A great variety of medications were taken by patients in both groups in an attempt to control their preoperative pain (Table V). These were narcotics, antibiotics,
nonsteroidal anti-inflammatories, acetaminophen, and over-the-counter topical anesthetics, in addition to any number of combinations of these. Ibuprofen was the most popular nonsteroidal anti-inflammatory medication used in either group. The use of ibuprofen may be related to effective product advertising and marketing. Less than a quarter of the patients (irreversible pulpitis, 23%; symptomatic teeth with necrotic pulps, 20%) reported taking some form of narcotic-containing pain reliever. This is most likely because of the unavailability of these types of medications in over-the-counter form. We found that patients received their medications from various sources, including hospital emergency rooms, friends, relatives, and drug stores, or had medications remaining from previous unrelated therapies. Within the group with irreversible pulpitis, significantly more women took an analgesic medication than men (Table VI). This difference was not significant in the group with symptomatic teeth with necrotic pulps (Table VII). There were no differences found between the sexes for narcotic or nonnarcotic analgesic usage within either group. These results parallel the findings reported by Eggen26 and Antonov and Isacson.27 In both of those studies, to control pain, women used analgesics more frequently than did men. Thus, women may resort to an analgesic medication more frequently than do men to help control the pain of irreversible pulpitis. However, in symptomatic teeth with necrotic pulps, men may report more relief of their moderate to severe pain after taking an analgesic medication (Table VII). CONCLUSION In this study of patients with moderate to severe pain seeking emergency endodontic treatment, we found that patients with irreversible pulpitis will wait longer (9 days) than those with a symptomatic tooth with a necrotic pulp (4 days) before seeking emergency treatment. A majority (81%-83%) of these patients will have taken some type(s) of medication (narcotic, 20%23%; nonnarcotic, 75%-80%; antibiotic, 6%-10%) to help control their pain. The patient’s pain will be relieved approximately 62% to 65% of the time with the medication(s). Men will have more pain relief than will women in symptomatic teeth with necrotic pulps, but women will take an analgesic medication more often than men in cases of irreversible pulpitis. REFERENCES 1. Topazian RG. Pain thresholds and factors which modify them. Oral Surg Oral Med Oral Pathol 1957;10:1192-1203. 2. Hardy JD. The nature of pain. J Chronic Dis 1956;4:22-51. 3. IASP Subcommittee on Taxonomy. Pain terms: a list with definitions and notes on usage. Pain 1979;6:249-52. 4. O’Keefe EM. Pain in endodontic therapy: preliminary study. J Endod 1976;2:315-9.
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Reprint requests: John Nusstein, DDS, MS Advanced Endodontics College of Dentistry The Ohio State University 305 W 12th Ave Box 182357 Columbus, OH 43218-2357 [email protected]