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Clinical Research

What Is the Effect of No Endodontic Debridementon Postoperative Pain for Symptomatic Teethwith Pulpal Necrosis?Raquel Sebastian, DDS, MS,* Melissa Drum, DDS, MS,† Al Reader, DDS, MS,†

John Nusstein, DDS, MS,† Sara Fowler, DMD, MS,† and Mike Beck, DDS, MA‡

Abstract
Introduction: Patients without a dentist or access tocare may present to emergency rooms with pain. Theyare often prescribed medications until they can betreated. There are no studies to show if emergency end-odontic debridement is better than giving medicationsduring this symptomatic period. The purpose of this pro-spective, randomized study was to compare debride-ment versus no debridement on postoperative pain inemergency patients with symptomatic teeth, a pulpaldiagnosis of necrosis, and a periapical radiolucency.Methods: Ninety-five patients presenting with moder-ate to severe pain were analyzed. The patients wererandomly divided into 2 groups: group 1 received anes-thesia and endodontic debridement, and group 2received anesthesia but no debridement. At the end ofthe appointment, all patients were given ibuprofen/acet-aminophen. If needed, they could receive an escapemedication. Patients received a 5-day diary to recordtheir pain levels and medication taken. Success wasdefined as no or mild postoperative pain and no useof escape medication. Success data were analyzed usinga logistic regression. Results: Both groups had adecrease in postoperative pain and medication useover the 5 days. The debridement group had a signifi-cantly higher success rate than the no debridementgroup. There was no significant difference betweenthe 2 groups with respect to escape drug use. Conclu-sions: Patients receiving debridement or no debride-ment had a decrease in postoperative pain over the5 days. Debridement resulted in a statistically highersuccess rate, but there was no significant difference inthe need for escape medication. (J Endod 2016;-:1–5)
Key WordsEndodontic debridement, endodontic pain, pulpalnecrosis, symptomatic endodontic patients

From the *Practice Limited to Endodontics, San Antonio,Texas; and Divisions of †Endodontics and ‡Biosciences, TheOhio State University, Columbus, Ohio.

Address requests for reprints to Dr Melissa Drum, The OhioState University, Postle Hall, 305 West 12th Avenue, Columbus,OH 43210. E-mail address: [email protected]/$ - see front matter

Copyright ª 2016 American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2015.12.001

JOE — Volume -, Number -, - 2016

Symptomatic teeth with a pulpal diagnosis of necrosis are frequently treated in aspecialty endodontic practice (1–5). Usually, accessing the tooth and performing

endodontic debridement are completed at the initial emergency visit. However,patients without a dentist or access to immediate dental care may present tohospital emergency rooms with dental pain and are often prescribed painmedication and antibiotics and referred to a dentist for evaluation and treatment(6). According to the National Hospital Ambulatory Medical Care Survey, dentalemergency room visits in the United States increased by 1 million from 2000 to2010 (7). A community dental health coordinator stated that she sees patients dailywho have waited too long for dental treatment. ‘‘Often, they’ve visited the emergencyroom and received antibiotics as a temporary treatment but haven’t followed up witha dentist to completely resolve their problem’’ (7). A retrospective analysis of pa-tients admitted to the emergency room with a diagnosis of periapical abscessshowed that over 9 years there were 61,439 hospitalizations because of periapicalabscess in the United States (8). In addition, the number of hospitalizationsincreased 41% from 2000 to 2008 (8). A study assessed the prevalence and costsassociated with emergency department visits in 2006 and found there were 403,149emergency department visits in a year associated with pulpal and periapical diseasetotaling $163,692,957 in hospital charges (9).

Dental emergency room visits were evaluated and described from 1997 to 2000 byLewis et al (6). There were 2.95million dental emergency department visits in total, andat least 1 prescription was given in more than 80% of visits; antibiotics were prescribedin 49% of visits, whereas 72% of patients received analgesics (38% received a narcoticprescription). The dental emergency department visits were more likely to occur on theweekend when many dental offices were not open (6).

Although many emergency room physicians recommend more definitivefollow-up care, it is not known how many of these patients follow through withthis recommendation. Dental-related emergency room visits from 5 major hospitalsystems in Minneapolis over 1 year showed that over 10,000 visits were related todental problems (10). Of these 10,000 visits, 2,499 were second or additionalrepeat visits for a dental problem. Therefore, about 20% of the dental-relatedemergency room visits were repeat visits. A major concern with the treatmentof dental problems in a hospital setting is the lack of follow-up and definitivedental treatment (10–12).

Although it is known that patients are commonly prescribed antibiotics and painmedication for dental pain in the emergency room, it is not known what happensto these patients once they leave the hospital setting (6). If they do not seekimmediate dental treatment, what is the amount and duration of postoperativepain they experience?

There are currently no studies to show if initial endodontic debridement isbetter than just placing the emergency patient on medications for pain relief duringthis symptomatic period. The purpose of this prospective randomized study was tocompare the effects of endodontic debridement versus no endodontic debridementon postoperative pain in emergency patients with symptomatic teeth, a pulpal diagnosisof necrosis, and a periapical radiolucency.

Symptomatic Teeth with Pulpal Necrosis 1

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http://dx.doi.org/10.1016/j.joen.2015.12.001

TABLE 1. Preoperative Variables for the Debridement and No DebridementGroups

Variable DebridementNo

debridement P value*

Age (y)† 36 � 12 39 � 17 .3666Sex 20 female,

26 male25 female,

24 male.4616

Presenting pain‡ 119 � 27 120 � 27 .9088Corah anxiety

(median)9 9 .3952

Tooth location .3914Anterior 7% (3/46) 12% (6/49)Premolar 26% (12/46) 16% (8/49)Molar 67% (31/46) 71% (35/49)

Jaw .9105Maxilla 52% (24/46) 51% (25/49)Mandible 48% (22/46) 49% (24/49)

*There were no significant differences between the 2 groups.†Mean � standard deviation.‡Mean � standard deviation, Heft-Parker VAS ratings.

TABLE 2. Logistic Regression Summary for Treatment Success

Type III tests of fixed effects

EffectNumDF

DenDF Chi-square

Pr >Chi-square

Group 1 546 5.09 .0241Day 5 546 32.93 <.0001Group by day 5 546 4.64 .4608Sex 1 546 10.57 .0011Group by sex 1 546 1.27 .2593Sex by day 5 546 3.74 .5879Group by sex by day 5 546 5.72 .334

Odds ratio estimates

Estimate DF

95%confidence

limits

Group (debridement vs nodebridement)

1.519 546 1.055 2.185

Sex (female vs male) 0.548 546 0.38 0.788

Clinical Research

Materials and MethodsOne hundred eight adult patients presenting for emergency treat-

ment initially participated in this study. All subjects were in good phys-ical condition as determined by a written questionnaire and oralquestioning. Each patient was required to be 18 years or older andbe in good health with an American Society of Anesthesiologists classi-fication of I or II. Patients were excluded from the study if they were tak-ing chronic pain medications; if they were allergic to local anesthetics,ibuprofen, acetaminophen, or codeine; if they reported a history ofgastrointestinal problems, angioedema, or bronchospastic activity toaspirin or other nonsteroidal anti-inflammatory drugs; or if they wereunable to give informed consent. In addition, prisoners and mentallydisabled patients were excluded. All female subjects were questionedregarding pregnancy or suspected pregnancy. None were allowed toparticipate if they were pregnant, suspected of being pregnant, orwere trying to conceive. Approval for this study was obtained fromthe university’s human subjects review committee, and written consentwas obtained from each participant.

Each patient had a distinct radiolucency at the apex of a symptom-atic tooth and a diagnosis of pulpal necrosis as shown by a negativeresponse to an electric pulp tester (Analytic Technology Corp, Red-mond, WA) and Endo-Ice (Hygenic Corp, Akron, OH). Patients werealso required to have no or mild swelling and no draining sinus tract.The patient’s temperature was taken orally using the SureTemp digitalthermometer (Welch Allyn Ltd, Navan, CO), and any patient with a tem-perature above 100�F was excluded from participation.

Each patient rated his or her initial pain on a Heft-Parker visualanalog scale (VAS) (13). The VAS was divided into 4 categories asdescribed previously (5). To qualify for the study, patients had to pre-sent with moderate to severe pain. Each patient also completed theCorah Dental Anxiety Scale questionnaire (14).

Before the experiment, the 2 regimens (debridement or nodebridement) were randomly assigned 5-digit numbers from a randomnumber table. The number assignment determined whether debride-ment or no debridement was performed for each patient. Only therandom numbers were recorded on the data collection sheet to main-tain blinding of the experiment.

Each patient was anesthetized with 2 cartridges of 2% lidocainewith 1:100,000 epinephrine (Xylocaine; AstraZeneca LP, Dentsply,York, PA) administered by an inferior alveolar nerve block or maxillaryinfiltration. Patients in the debridement group had the affected toothisolated with a rubber dam and endodontic debridement performed us-ing 3% sodium hypochlorite irrigation and hand and rotary files. Thecanals were prepared to a minimum size of a 30/.04 or 40/.04 depend-ing on the tooth and canal treated. The canals were dried with paperpoints, and calcium hydroxide (Multi-Cal; Pulpdent Corp, Watertown,MA) was placed as an intracanal medicament. The teeth were tempo-rized with Cavit (Cavit G; 3M ESPE, Seefeld, Germany), and the patientswere scheduled for root canal completion. The senior author (R.S.)performed all endodontic treatment.

For the no debridement group, local anesthesia was administeredusing 2 cartridges of 2% lidocaine with 1:100,000 epinephrine asdescribed previously. This completed the treatment phase.

If patients presented to the clinic already taking an antibiotic, theywere instructed to finish their current regimen if the antibiotic anddosage were clinically appropriate. Patients who were not on antibioticsor were not prescribed an appropriate antibiotic regimen received aprescription for an antibiotic (500 mg penicillin; if allergic, 300 mgclindamycin) to be taken every 6 hours until gone. Antibiotics wereadministered because a number of presenting patients were alreadyon antibiotics, and we wanted to eliminate this variable from the study.

2 Sebastian et al.

The patients in both groups were also given a 5-day supply of600 mg ibuprofen (Amneal Pharma of NY, Hauppage, NY) with instruc-tions to take 1 tablet every 6 hours as needed for pain and a 5-day sup-ply of 500 mg acetaminophen (Amneal Pharma of NY) withinstructions to take 2 tablets every 6 hours as needed for pain. Thepain medications were placed in separate amber pill bottles, but thepatient was instructed to take both medications at the same time.The bottles were affixed with different colored labels (1 color foribuprofen and another color for acetaminophen) containing thedrug information including the name, dose, quantity, and medicationinstructions. The patients were instructed not to take any other pain orantibiotic medications. If the ibuprofen/acetaminophen was not man-aging their pain, the patients were instructed to call an assigned cellphone number that was carried by the investigator. After speakingwith the investigator, if an escape medication was needed, hydroco-done/acetaminophen (5/500mg, 16 tablets, 1–2 tablets every 6 hours)was prescribed. Because of the changes to the drug formulation duringdata collection, some patients received hydrocodone/acetaminophen5/325 or hydrocodone/acetaminophen 5/300 based on pharmacy


TABLE 3. Percentages and Discomfort Ratings of Postoperative Pain for the Debridement and No Debridement Groups (excluding patients who took narcotics)

Group None Mild Moderate Severe Median P value

Day 0*Debridement 3% (1/37) 35% (13/37) 54% (20/37) 8% (3/37) 58.0 .8587No debridement 9% (4/42) 38% (16/42) 38% (16/42) 14% (6/42) 57.5

Day 1Debridement 8% (3/36) 42% (15/36) 47% (17/36) 3% (1/36) 52.0 .0982No debridement 7% (3/43) 26% (11/43) 60% (26/43) 7% (3/43) 59.0





*Night of treatment when local anesthesia wore off.

TABLE 4. Mean Number of the Combination Medications Taken (excludespatients who took narcotics)

GroupNumber ofpatients

Mean numbertablets P value

Day 0*Debridement 37 4.8 � 2.7 1.0000Nondebridement 43 4.4 � 3.1

Day 1Debridement 37 6.3 � 3.8 .7874Nondebridement 43 7.8 � 3.9

Clinical Research

availability. The patient was instructed to stop taking the ibuprofen andacetaminophen once starting the escape medication to avoid exceedingrecommended drug dosing. The patient was seen emergently in theclinic if the need arose.

Patients received a diary for the day of the appointment and 5 dayspostoperatively to record any pain they were having and the amount ofpain (ibuprofen/acetaminophen combination or escape) medicationtaken. Patients recorded the type and number of pain medications takenduring the time period between the completion of the endodontic pro-cedure and before going to bed the night of the appointment after thelocal anesthesia had worn off. For the next 5 days, patients recordedpain on the Heft-Parker VAS and the type and number of pain medica-tions taken each day. Patients were asked to return all unused medica-tions upon completion of the study to verify diary input. The patientsassigned to the no debridement group were scheduled for endodontictreatment 5 days later or at their earliest convenience. Successwas defined as none or mild postoperative pain and no use of narcoticmedications. Overall success was calculated for the debridement and nodebridement groups.

The data from this study were statistically analyzed. Comparisonsbetween the debridement and no debridement groups for age and initialpain ratings were made using the randomization test. Comparisons insex and jaw were analyzed via chi-square tests. Differences in toothtype were analyzed using the Fisher exact test. Corah anxiety ratingswere assessed using the Mann-Whitney-Wilcoxon test.

Between-group differences in success were evaluated using arepeated measures logistic regression with group, day, and sex as theindependent variables. A mixed model analysis of variance with postop-erative day, patient sex, and treatment group as the independent vari-ables was used to evaluate total analgesic use. Tooth type and jaw

Figure 1. Postoperative pain by group and day.


were included as random variables. Post hoc testing was performed us-ing the Tukey-Kramer procedure. Because the postoperative pain valueswere not normally distributed, they were analyzed nonparametricallyusing multiple randomization tests with the P values adjusted usingthe step-down Bonferroni method of Holm. Comparisons were consid-ered significant at P < .05. For VAS pain scores, assuming a standarddeviation of 50.3 (5), a difference of �30 mm could be detectedwith a power of 0.80 with 45 patients per group.

ResultsA total of 108 subjects were enrolled in this study. Thirteen sub-

jects were disqualified for the following reasons: 1 because of a fracturedetected upon endodontic access, 11 for not returning postoperativesurveys, and 1 for not disclosing the use of Percocet daily for chronicback pain. Ultimately, 10 patients were disqualified from the debride-ment group, and 3 patients were disqualified from the no debridementgroup. Therefore, the total number of subjects analyzed was 46 in thedebridement group and 49 in the no debridement group.





*Night of treatment when local anesthesia wore off.


Figure 2. Combination ibuprofen/acetaminophen use by day.

Clinical Research

Table 1 shows the preoperative variables. There were no statisti-cally significant differences between the 2 groups with regard to age,sex, presenting pain, Corah anxiety ratings, tooth location, or jaw.

Table 2 shows the regression summary for treatment success.There were significant effects for treatment group (odds ratio =1.519; 95% confidence interval, 1.055–2.185 for debridement vs nodebridement), sex (odds ratio = 0.548; 95% confidence interval,0.380–0.788 for females vs males), and day. All interaction effectswere not significant (P > .259).

Table 3 shows pain by day for the debridement and no debride-ment groups. Moderate to severe pain was experienced by 52%–62%of the patients the night of the treatment and 50%–67% of the patientson day 1, with the pain ratings decreasing over the next 4 days. Signif-icantly lower pain values were noted for the debridement group for days3 through 5. Figure 1 shows the postoperative pain ratings over the 5days.

Table 4 and Figure 2 show the mean number of combinationibuprofen/acetaminophen tablets taken by day for the debridementand no debridement groups. The highest number of medication usewas on day 1, with decreasing use over the next 4 days. Twenty percent(9/46) of patients in the debridement group and 12% (6 of 49) in theno debridement group took escape medications with no significant(P = .3218) difference between the groups (Fig. 3).

Figure 3. Escape drug use.

DiscussionDifferences in the preoperative variables would be minimized

because no statistically significant differences were shown betweengroups (Table 1). The presenting initial moderate pain level(Table 1) is representative of emergency patients with symptomaticteeth, a pulpal diagnosis of necrosis, and a periapical radiolucency asshown byWells et al (5). Becausemost subjects in both groups reportedlow to moderate Corah scores (Table 1), anxiety may not have played alarge role in influencing the pain associated with debridement or nodebridement. The influence of tooth location was minimized becausethe teeth were evenly distributed (Table 1).

The debridement group had a significantly higher odds of success(no to mild pain and no narcotic use) than the no debridement group.Therefore, the best clinical outcome would be to completely debride thetooth at the emergency visit. Endodontists would be likely to performcomplete debridement because of their advanced training and experi-ence. However, inexperienced operators may not be able to performcomplete debridement at the emergency visit.

The patients in the no debridement group did not get worse overthe 5 days, indicating that analgesics may help these symptomatic pa-tients presenting with a necrotic pulp and associated periapical radio-lucency. The use of antibiotics would not be expected to help becausethe use of antibiotics does not result in a significant improvement in the

4 Sebastian et al.

resolution of symptoms of symptomatic teeth with pulpal necrosis oracute apical abscesses (3, 15). If the patient is immunocompromisedor has significant medical conditions, perhaps complete debridementwould be indicated versus no debridement.

Although pain was reduced from presenting pain levels, mod-erate to severe pain levels were still reported by 52%–62% of thepatients the night of the treatment and 50%–67% of the patientson day 1 (Table 3). Most medication usage was in the first severaldays and decreased over the 5 days paralleling the decreasing pain(Table 3, Fig. 2). The decrease in tooth pain over the 5 days is mostlikely attributable to the natural course of the disease process for theclinical condition of a symptomatic tooth with a necrotic pulp and anassociated periapical radiolucency. Other authors (1–5) showed thatthe majority of patients started to improve regardless of drug oractive treatment protocols on the third postoperative day. Ourresults confirm these observations. Patients improved even withoutemergency debridement.

Twenty percent (9/46) of patients in the debridement groupand 12% (6 of 49) in the no debridement group took escape med-ications with no significant (P = .3218) difference between thegroups (Fig. 3). Wells et al (5) found 20% of patients used escapemedication (Vicodin) when the combination of ibuprofen and acet-aminophen was ineffective for pain control in symptomatic patientswith a necrotic pulp and an associated periapical radiolucency whowere experiencing moderate to severe preoperative pain. There-fore, the combination of ibuprofen and acetaminophen wouldnot be completely effective for controlling postoperative pain inthese patients. However, even with no debridement, most patientsdid not require escape medication. Symptom improvement withouttreatment and lack of narcotic use may be important in certainclinical scenarios.


Clinical Research
We concluded patients receiving debridement or no debridement
had a decrease in postoperative pain and medication use over the5 days. Complete endodontic debridement resulted in a statisticallyhigher success rate when compared with no endodontic debridement,but there was no significant difference in the need for escape (narcotic)medication between the 2 groups.

AcknowledgmentsThe authors deny any conflicts of interest related to this study.

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