Pain management during endodontic treatment of mandibular posterior teeth: a narrative review

Introduction

Background

Effective pain management is essential in dentistry, especially during the endodontic treatment of dental emergencies. This not only benefits the patient by preventing unintentional injury due to sudden patient movement or reactions, but it also benefits the dentist (1). In the case of maxillary teeth, the most appropriate technique for pain management during endodontic treatment would be buccal infiltration (BI) close to the level of the apices of the teeth. Since the maxillary bone is porous, this facilitates easy diffusion of the anesthetic solution. However, the teeth that are most difficult to anesthetize are the mandibular molars, followed by the mandibular premolars, and mandibular anterior teeth. The main reason for this is that the cortical plates of the mandible are thicker and denser and have less porosity, which does not allow local anesthetic to diffuse into the cancellous bone (2). Achieving successful pulpal anesthesia in mandibular posterior teeth can be even more challenging for patients with irreversible pulpitis. Several reasons have been attributed to this, including: (I) the decreased pH in inflamed tissue reduces the amount of the base form of anesthetic that penetrates the nerve membrane, thus less of the ionized form is available in the nerve to achieve anesthesia; (II) altered resting potentials and decreased excitability thresholds in inflamed tissues; (III) the expression of tetrodotoxin (TTX)-resistant voltage-gated sodium channels, which are resistant to local anesthetic action, is increased in the primary sensory neurons due to the increase of prostaglandin numbers; (IV) the overexpression of sodium channels; and (V) patients in pain are often apprehensive, which lowers the pain threshold (3).

Rationale and knowledge gap

Numerous approaches have been explored for efficacy of pain management to enhance the effect of local anesthesia (LA) injections in symptomatic irreversible pulpitis particularly mandibular posterior teeth. These techniques include repeat inferior alveolar nerve block (IANB), increasing the volume of local anesthetic administered, and utilizing supplemental injection methods. Additionally, preoperative medication with non-steroidal anti-inflammatory drugs (NSAIDs), anxiolytic agents, and other medications has been studied to improve the success rate of IANB injections for effective pain control prior to treatment.

Objective

The intention of this review article is to present a thorough examination of both conventional and advanced methods for managing pain during endodontic therapy at preoperative, perioperative, and postoperative stages. Furthermore, the article aims to serve as a comprehensive resource for endodontic practitioners and researchers, offering insights into the multifarious aspects of pain management during endodontic treatment of mandibular posterior teeth. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-11/rc).

Methods

In conducting this narrative review, a comprehensive search was undertaken using PubMed, Scopus, Science Direct, and Google Scholar (Table 1). The search process involved the manual application of keywords, incorporating terms such as “pain management”, “endodontic”, “preoperative pain medication”, “postoperative pain medication”, “interappointment pain”, “perioperative pain”, “analgesia”, and “anesthesia”. The selection criteria were focused on articles that were directly related to the topic or had a significant association with the subject matter. The inclusion criteria were articles in English, literature relevant to the expert consensus, and relevance to our study. Duplicates were excluded. The review comprised controlled trials, cohort studies, systematic reviews, and meta-analyses. The review encompasses literature published from 1990 to 2023, as well as articles identified through references in the initially retrieved papers.

Pain management strategies

Pain from endodontic therapy has traditionally been overstated. Efforts to improve pain treatment procedures in clinical practice have been underway for many years; however, maintaining adequate pain management is a continuous challenge. It is well known that providing effective pulpal anesthesia during root canal treatment for individuals with symptomatic irreversible pulpitis might be difficult to determine (4).

Preoperative strategies

Behavioral management

When a patient visits the dentist for the first time, behavioral management is definitely vital throughout therapy, between sessions, as well as post-treatment (5).

Managing dental pain in anxious patients during and after treatment continues to be an important concern. Researchers have proposed a link between pain and anxiety: the higher the anxiety, the more likely we are to interpret the sensation as pain. In a clinical investigation of children, anxiety was revealed to be the most powerful predictor of poor intraoperative pain control. Similarly, when individuals are anxious, their pain threshold decreases. Highly apprehensive patients are more susceptible to pain in general, and dentally concerned individuals are more sensitive to dental pain (6).

It has been estimated that 4–40% of people suffer from dental anxiety (7,8). Because anxiety is caused by uncertainty, providing information about the procedure and boosting the patient’s sense of control may significantly reduce anxiety (9).

In 1983, Friedman and colleagues introduced the “iatrosedative technique”, a systematic approach to “making the patient calm by the dentist’s behavior, attitude, and communicative stance” (10). Logan et al. found that providing sensory and procedural information to patients undergoing endodontic treatment lowered pain levels (11).

Psychological behavioral therapy can effectively alleviate acute dental discomfort without intrusive procedures. Psychological therapies might take the shape of diversion methods, perception of sensations, perceived control, or pleasant dental experiences (12). Distraction tactics can include visual stimuli, music, and explanations of predicted sensations, such as rotor noise, prior to starting the treatment.

For younger patients, recommended strategies include using lavender fragrances, immersing them in discussions, and creating rapport through tactics including voice control, diversion, modelling, and memory reconstruction (9). Research indicates that psychosocial assistance is beneficial for patients experiencing acute dental discomfort.

Premedication

Pretreatment with analgesic medications or additional injections may be beneficial for those with low pain tolerance. Pre-operative medicine can alleviate discomfort and inflammation at the treatment site after a diagnosis (13).

Inflammatory mediators can stimulate pain fibers even at low thresholds, resulting in improper anesthesia. Inflamed pulps may have higher levels of TTX-resistant sodium channels, making them less susceptible to LA (7).

To improve the anesthetic efficacy of 2% lidocaine when administered as an IANB, professionals have investigated the most appropriate combination of medications to use in conjunction with LA (14). Therefore, utilizing NSAIDs and corticosteroids as premedications can enhance anesthesia success rates. One dosage of 10 mg ketorolac or 100 mg tapentadol given half an hour prior to endodontic procedure orally reduced postoperative pain considerably in comparison to 400 mg etodolac (15). Additionally, corticosteroid premedication before administration of IANB resulted in a significantly greater success rate (16).

Premedication with ibuprofen (>400 mg) has been linked to a higher success rate of LA after IANBs (17).

Analgesics

Effective management of sensitive and uncomfortable regions is crucial in dental practice as it directly impacts patient quality of life (18). Pulpal discomfort can develop during various stages of treatment (preoperative, perioperative, and postoperative).

Drug strategies should be tailored to each clinical patient, including pre- and post-operative conditions (19). The use of drugs to control the pain should be planned rationally and strictly to situations requiring pharmacological management, adjunctive to the dental treatment (20).

Acetaminophen and NSAIDs are currently the primary medications used to treat dental-related pain (21).

NSAIDs

NSAIDs suppress prostaglandin production by decreasing the activities of cyclooxygenase (Cox) 1 and Cox 2 (22). This kind of intervention is crucial for alleviating painful symptoms in patients with dental problems (23).

Pre-treatment with NSAIDs in cases such as irreversible pulpitis should have the effect of reducing pulpal levels of the inflammatory mediator prostaglandin E2 (PGE2). This would benefit in two ways. Firstly, decreasing pulpal nociceptor sensitization would mitigate an increase in resistance to local anesthetics (24). Secondly, it may diminish a prostanoid-induced stimulation of TTX-resistant sodium channel activity; these channels also display relative resistance to lidocaine (25). Ibuprofen 400 and 800 mg are the safest NSAIDs. Aside from ibuprofen, dentists frequently prescribe diclofenac potassium 50 mg, naproxen sodium 500/550 mg, etoricoxib 120 mg, and other NSAIDs for pain (26).

Diclofenac sodium, an NSAID that blocks Cox enzymes, is often used to treat dental discomfort and swelling after surgery. Jenarthanan et al. concluded that preventive intraligamentary diclofenac sodium injections were far more efficient than taken orally in alleviating post-endodontic discomfort (27).

Acetaminophen

Acetaminophen, also known as paracetamol or Tylenol, is widely used for relieving pain and reducing fever. It has been shown that the synergic interaction between NSAIDs and acetaminophen results in more analgesia, because acetaminophen’s mode of action variesfrom that of NSAIDs (28). Acetaminophen can be used as an alternative to NSAIDs for people allergic to aspirin-like medicines, however it is not as effective as ibuprofen in improving IANB success. A very large overdose of acetaminophen can lead to liver failure.

Corticosteroids

Even though not currently classified under analgesics, corticosteroids have been used for managing post-endodontic pain due to their anti-inflammatory effects. Also called “steroids”, they work by decreasing inflammation and reducing the immune response in the body. Several studies have confirmed their effectiveness in treating endodontic pain. The success rate of using corticosteroids as a premedication before an IANB injection was considerably higher. Steroids that are used in dentistry are glucocorticoids, corticosteroids, ledermix, dexamethasone, prednisolone, and triamcinolone acetonide (29).

Methylprednisolone, a powerful steroid that reduces inflammation, has been extensively explored for pain management. Bane and colleagues found that after 7 days, methylprednisolone injections proved to be more successful in treating acute pulpitis than pulpotomies, saving both dental resources and surgeon time. After 6 months, there was no apparent difference in the two groups’ therapy outcomes (30).

Opioids/narcotic analgesics

Although dentistry is a relatively small healthcare sector, it accounts for a large portion of opioid prescriptions, raising concerns (31). Because of this disturbing condition, opioid prescriptions are usually reserved for acute cases where nonnarcotic analgesics alone or in combination may not be sufficient to manage pain. Although opioids are clinically justified, prescribing them is challenging due to their substantial side effects (32). To move to safer pain management methods, dentists should receive comprehensive training and conduct robust research (33).

Therefore, the American Dental Association recommends that before prescribing opioids, dental care providers should conduct a medical and dental history to determine current medications, potential drug interactions and history of substance abuse, use their state’s prescription drug monitoring program, complete continuing education, and, above all, use non-narcotics as the first-line therapy for acute dental pain (34).

Trypsin-chymotrypsin

Trypsin-chymotrypsin proves beneficial in reducing postoperative inflammation and controlling painful symptoms because of its anti-inflammatory and antioxidant properties.

A randomized controlled trial (RCT) in 2003 found no meaningful difference in postoperative pain alleviation after a single visit endodontic therapy for symptomatic irreversible pulpitis in mandibular first molars with ibuprofen, trypsin-chymotrypsin, and combination groups, but resulted in significant pain alleviation compared to placebo (35).

Analgesic and antibiotic combination

The use of both antibiotics and analgesics are essential for managing tooth infections and pain. The literature on their use and potential overuse is substantial. Local antibiotic administration is a hot topic in both theory and clinical practice. To accomplish the finest results the use of medicaments in the root canal system, particularly antibiotics, is suggested due to the potential outcomes. Mittal and Jain found that using antibiotics locally as an intracanal medicament may be more effective than systemic use (36). Excellent results are shown when corticosteroids and antibiotics are used together as intracanal medicament (37).

Pain on injection

Topical anesthesia

Some studies suggest that topical anesthesia can reduce injection discomfort (38,39), whereas others observed no apparent effect on the amount of pain when an anesthetic solution is administered or during needle penetration (40,41). Topical anesthesia efficacy can be influenced by parameters such as the interval between application of topical anesthesia and injection, location of injection, and form of drug/concentration (39,41,42).

Topical anesthesia is recommended to be applied at the injection site at least 2 min prior the injection (42). Formulations containing 60% lignocaine or a combination of 2.5% lignocaine and 2.5% prilocaine have been shown to have greater effects than those containing 20% benzocaine (38,39). According to a study, 2% lidocaine hydrochloride patches considerably reduced the pain associated with needle insertion when compared to placebo and 20% ethyl aminobenzoate patches (43). Additionally, topical anesthetics might have a placebo effect, showing the patient that the dentist is concerned about their comfort while receiving treatment (44).

Intraoperative strategies

Anesthesia

The mission of every dental care provider is to eliminate and treat dental diseases with the least pain and discomfort for patients. Obtaining successful anesthesia during endodontic treatment is often complex and challenging in patients with dental pain of pulpal origin (45); however, all local anesthetics in dentistry are considered efficacious (46). Success rates of 13% to 54% were reported for IANB injection using 2% lidocaine and success rates of 33% to 63% were reported for IANB injections using 4% articaine.

Overcoming anesthetic failure

LA failure is an inherent part of dental practice. The IANB technique is routinely used by clinicians to anesthetize mandibular teeth. However, failure rates are high with a reported range in failure rate from 46% to 86% for mandibular molars (47).

Many RCTs investigated various strategies to overcome the difficulty of achieving pulpal anesthesia in patients with symptomatic irreversible pulpitis. These methods include changing the local anesthetic solution type, using buffered anesthetic solutions, increasing the volume of anesthetics, changing the injection technique for mandibular anesthesia (Gow-Gates technique), supplemental BI with articaine, and proven techniques such as intraosseous (IO) anesthesia, intraligamentary injection, also called periodontal ligament (PDL) injection, nitrous oxide, intrapulpal anesthesia and new formulations like Kovanaze Nasal Spray and EXPAREL (liposomal bupivacaine) (48).

Endodontic procedures often involve the use of local anesthetics, either alone or in combination with oral medications, in order to alleviate discomfort before and during the procedure. According to a recent study, premedication with diclofenac sodium and paracetamol, followed by IANB or IANB with 2% lidocaine, and buccal injection of 4% articaine were the most effective therapies in the mandible. Both therapies demonstrated higher efficiency than the control group (49). It has been observed that combining an IANB injection with two additional injections, namely a BI injection followed by an intraligamentary injection—significantly improves the success rate of LA for mandibular molars with irreversible pulpitis. This above method combines the effects of additional (supplementary) injections, higher volumes of anesthetic solution and multiple injection sites that target distinct nerves or nerve areas.

Volume of local anesthetic

Achieving optimal anesthesia depends partially on the amount of local anesthetic solution injected into the tissues. Regarding the impact of anesthesia volume on the success rates of IANB therapy in teeth with irreversible pulpitis, there are contradictory findings. Two studies (50,51) found that when administering IANB injections for the treatment of mandibular teeth with irreversible pulpitis, a higher volume of solution improved the success rate of LA. Two further studies, though (52,53), failed to find any significant difference.

Despite these findings, employing two cartridges of anesthetic solution for IANB injections has been demonstrated to improve the success rate of endodontic treatment for patients with no symptoms and irreversible pulpitis (54). A supplemental injection is an alternative technique of employing a larger volume of anesthetic solution (55). This involves another injection administered at a different location, usually with the goal of targeting multiple nerves or a different section of the same nerve.

Adjuncts for conventional IANB

Supplementary injection techniques

Supplemental injection procedures can overcome failures following the primary infiltration or blockages.

(I) BI

After IANB fails to work, BI is an additional technique for anesthetizing mandibular molar teeth. Systematic reviews and meta-analyses suggest that 4% articaine with 1:100,000 epinephrine is the preferred supplementary BI solution for mandibular molar teeth with irreversible pulpitis as the anesthesia success rates are substantially greater than with 2% lidocaine (56,57). Articaine is more effective than lignocaine for bone diffusion, making it a viable supplementary or primary BI method (58).

Simpson et al. came to the conclusion that BI with 4% articaine and epinephrine (1.8 mL) after IANB failure resulted in a 24–38% success rate for mandibular molars with irreversible pulpitis (59).

Kanaa et al. observed an 84% success rate with additional BI with articaine, which was significantly greater than intraligamentary injection with either repeat IANB (32%) or 2% lidocaine combined with epinephrine (48%) following IANB failure (60). Administration of a buccal injection 5–10 min following an IANB injection would be a good approach to be sure about the success of the IANB injection (61).

(II) Intraligamentary injection

After IANB failure, this is the most often utilized technique for the treatment mandibular molars with irreversible pulpitis. While Smith et al. reported a 93% success rate in intraligamentary injection following IANB failure (62), Walton and Abbot reported a 63% success rate in the first intraligamentary injection and a 92% success rate in the reinjection for endodontic operations following IANB failure (63). The onset of action is immediate and has 30- to 45-min anesthesia duration.

There was no considerable difference in the anesthetic efficacy of 2% lidocaine and 4% articaine (both with 1:100,000 epinephrine) utilized for PDL injections in terms of the ability to anesthetize teeth with irreversible pulpitis (64). Malamed advised against performing intraligamentary injections on inflamed or unhealthy periodontal areas (65). It is not suggested for primary teeth as it has been linked to hypoplasia in enamel or hypomineralization in permanent teeth surrounding the injection site (66).

(III) IO anesthesia

It is more invasive than intraligamentary and is carried out using the perforator, specializedsystem (e.g., Stabident, X-Tip). Success rates for IO injection following IANB failure ranged from 66% to 91%, which was significantly higher than the rates for intraligamentary injection at 48% and repeat IANB at 32% (67). IO anesthesia should not be used if there is periodontitis or acute periapical infection, as it may cause a fistula. Lastly, use intraligamentary and intraosseus anesthesia with caution in cardiac patients.

(IV) Intrapulpal injection

Despite the primary injection and supplemental procedures, roughly 10% of teeth may not be anesthetized. Intrapulpal injection ought to be reserved as the final resort due to its intense pain level.

Although this technique has the benefit of a rapid anesthetic onset, its indication is limited to endodontic treatments involving exposed pulp (68).

Post-operative strategies

An all too common sequela of nonsurgical endodontic treatment is self-limiting post-op pain that can linger for about a week. Therefore, accurate knowledge regarding pain after root canal treatment and related factors will enable clinicians to predict and effectively manage postoperative pain. The incidence of postoperative pain during the first 24–48 h ranged from 3% to 69.3% (69).

Postoperative discomfort after nonsurgical root canal therapy is often caused by periradicular tissue inflammation, which is commonly caused by microorganisms (70). Apart from missing canals, mechanical or chemical injury to the periapical tissues can also result in postoperative discomfort. There is a significant correlation between preoperative and postoperative discomfort.

Patients with acute preoperative pain may suffer more severe postoperative pain (69,71). The incidence of pain after nonsurgical root canal treatment is also higher in mandible and in molars (72). The dense trabecular pattern of the mandibular bone, which restricts blood flow and concentrates infection, thereby delaying healing may be the cause of this discrepancy (73). Similar effects have been linked to the lower molars’ complicated anatomy (74).

Management of post-endodontic pain

Endodontic techniques and devices, including dental operative microscopes, electronic apex locators, and rotating nickel titanium systems, have resulted in shorter procedures and higher success rates (75). In addition, reciprocating systems and nickel titanium engine-driven instrumentation extrudes less debris than manual stainless steel K-files.

Using pretreatment analgesia half an hour before root canal therapy helps alleviate postoperative discomfort, particularly for patients with low pain thresholds. To reduce post-operative discomfort, it’s crucial that patients begin taking pain relief medication as soon as feasible after therapy (76).

Moreover, the described clinical protocols, optimizing post-operative endodontic pain control, should be integrated with the presented recommendations on post-operatively administered oral medicaments, proposing the use of ibuprofen (600 mg) alone and combined with acetaminophen (1,000 mg) as a first choice treatment, or ketoprofen (50 mg) as well as naproxen (500 mg) 6 h post-operatively, also in the perspective of minimizing drug intake, as it may be especially relevant in fragile and elderly subjects (77). Combining NSAIDs plus acetaminophen, or ibuprofen and paracetamol, may deliver better relief from pain after endodontic treatment.

Providing patients with information about expected postoperative pain and prescribing drugs can boost confidence, enhance pain thresholds, and improve their perception of future dental treatments.

Furthermore, there is scope to explore potential future solutions for pain management that could offer significant advantages.

Summary

Steps to manage pain during endodontic treatment of a MANDIBULAR molar tooth with acute irreversible pulpitis.

• To enable accurate diagnosis take complete history of symptoms;
• Consider premedication with NSAIDs;
• Standard local anesthetic injection for the affected tooth (e.g., IANBs);
• Allow enough time for the earliest signs of LA to manifest (e.g., lip numbness takes at least 5 min);
• Administer supplementary LA injections (e.g., BI);
• Allow adequate time for LA to work (at least 15 min from when the IANB block was given);
• Give LA extra time to work—at least 15 min after the IANB block was delivered;
• Use the cold pulp test to examine the tooth:
  • If profound LA, continue with treatment, but be ready for discomfort;
  • If LA is insufficient, consider administering a second one (e.g., repeating the initial injection or use an alternate block technique);
• Allow more time for the extra injections to work (at least 15 min);
• Re-test using the cold pulp test:
  • If profound LA, continue with treatment, but be ready for discomfort;
  • If LA is insufficient, consider administering supplementary intraligamentary injections;
• After 1–2 min, re-test with cold pulp test:
  • If profound LA, continue with treatment, but be ready for discomfort;
  • If LA is insufficient, consider additional intraligamentary injections;
• Before starting treatment, turn off handpiece water spray:
  • If pain occurs upon reaching dentine, consider administrating additional supplementary intraligamentary injections;
  • If pain occurs upon reaching pulp chamber, administer intra-pulp injection;
  • If pain occurs during instrumentation of root canal system, administer intra-pulp injection inside the canals or consider using topical LA gel in the canals;
  • If pain persists, perform a pulpotomy only (or minimal root canal treatment) and place a corticosteroid/antibiotic medicament in the root canals;
• Arrange post-operative pain medication.

Strengths and limitations of the review

Our review covers a broad range of literature over a period of 20+ years related to pain management in endodontics and discusses traditional analgesics, antibiotics, and the use of corticosteroids. This wide span of coverage allows the reader a comprehensive overview of effective pain management techniques during endodontic treatment especially in mandibular molars. This narrative review has limitations that need careful review and consideration. The inclusion and exclusion criteria omitted articles that were not written in English which could have eliminated data and insight from other studies. Again, presented here are only recommendations and guidelines based on the literature and the reader must establish best practices for their own institutions.

Conclusions

Successful management of endodontic pain prior to and throughout the treatment, as well as post root canal procedure is crucial to help the patient get relieved of the unpleasant sensation of pain. So, the effectiveness of pain management relies on multiple approaches beginning with a thorough knowledge of the pathologic problem, establishing an accurate diagnosis, and, in certain situations, the use of NSAIDs as premedication. Currently, there isn’t a single, effective way to reliably and completely reduce discomfort during root canal therapy especially for teeth (and particularly mandibular molars) with irreversible pulpitis. However, standard local anesthetic solutions and injection techniques along with increased volumes and specific supplementary injections for the various tooth types will usually enable clinicians to commence endodontic therapy and using intracanal medicaments to reduce discomfort. Following completion, use of flexible post-operative techniques to reduce incidence of pain should be taken into consideration that attend to each patient’s specific needs and condition(s) being treated.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-11/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-11/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-11/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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