The use of an intra-oral injection of ketorolac in the treatment of irreversible pulpitis

AIM: To examine whether an intra-oral injection of a nonsteroidal anti-inflammatory drug (ketorolac), in association with conventional local anaesthetic techniques, would improve the pulp extirpation rate in teeth with irreversible pulpitis. METHODOLOGY: A two group double-blind clinical trial was undertaken in the Dental Casualty Department of the University of Manchester School of Dentistry. Patients were randomly allocated to either the test or control group. The test group received an intra-oral injection of ketorolac (30 mg in 1 mL) in the buccal sulcus adjacent to the tooth being treated. After an interval of 15 min, they then received 2.2 mL of 2% lidocaine with 1 : 80 000 epinephrine by buccal infiltration in the maxilla or by inferior dental block in the mandible. The control group received an intra-oral injection of normal saline (1 mL) in the buccal sulcus adjacent to the tooth being treated, followed by the same local anaesthetic regime as the test group after the 15 min interval. Fifteen minutes after the local anaesthetic injections, pulp extirpation was attempted. All patients completed the short-form McGill pain questionnaire prior to treatment and completed identical questionnaires at 6 and 24 h after treatment. RESULTS: The study protocol set the number of patients to be treated at twenty. However, as the study progressed it became apparent that the intra-oral injection of ketorolac caused significant pain to four of the five patients who received it; therefore the study was terminated after ten patients had been treated. The results from the patients treated showed no significant difference in the pulp extirpation rate between the test and control groups. However, patients with higher pain scores at baseline were less likely to have the pulp completely extirpated, irrespective of whether they were in the test or control group. Pain scores for all patients decreased significantly from baseline to 24 h. CONCLUSION: An intra-oral injection of ketorolac did not improve the pulp extirpation rate in a small group of patients with irreversible pulpitis compared with a placebo. In addition, it was associated with such significant pain on injection that it cannot be recommended as a treatment in this situation.     

Efficacy of Endo-Ice followed by intrapulpal ice application as an adjunct to inferior alveolar nerve block in patients with symptomatic irreversible pulpitis—a randomized controlled trial

Clinical Oral Investigations - The purpose of the present study was to evaluate the effect of Endo-Ice followed by intrapulpal ice application for reducing pain during pulp extirpation in...     

Pulpal Injury: Pathology,Diagnosis And Periodontal Reactions

Diagnosis of pulpal disease can be difficult due to the lack of diagnostic signs and symptoms available to the practitioner. An understanding of the possible underlying pathological processes, combined with an exact assessment of the pain history, and appropriate clinical tests, should aid the practitioner in determining the nature of pulpal inflammation, and differentiating it from dentine sensitivity and cracked teeth. The responses of the pulp to traumatic injury to the periodontal membrane (PDM) require special consideration, particularly with respect to the assessment of pulp vitality, and the determination of cases requiring pulp extirpation in order to avoid inflammatory root resorption. Although the pulp is relatively isolated from the rest of the dentoalveolar complex by a dentine/cementum barrier, it is important to remember that it can communicate with the PDM through apical and lateral foramina, and areas of damaged cementum. Hence, it is a priority to both preserve the integrity of the cemental layer in cases of traumatic injury and periodontal disease, and to prevent the inflammation and resorption associated with periapical lesions by accurate diagnosis of irreversible pulpitis and pulp necrosis, followed by appropriate endodontic debridement procedures.     

Expression of NaV-1.7, TNF-α and HSP-70 in experimental flare-up post-extirpated dental pulp tissue through a neuroimmunological approach

BackgroundDental caries continue to represent a major problem which, if left untreated, will cause irreversible pulpitis. Root canal treatment constitutes one potential treatment intended to preserve teeth afflicted with irreversible pulpitis. During root canal treatment, pain or swelling, referred to as flare-ups, can occur at any point in the process.AimTo analyze the molecular aspect of the phenomenon of flare-up in vital dental pulp tissue following mechanical and bacterial trauma (extirpation and lipopolysaccharide [LPS] induction respectively) through a neurological approach, based on the expression of NaV-1.7 in neuron cells, and HSP-70, TNF-α in macrophage cells.MethodThis laboratory experimental study was conducted using 15 Spraque Dawley rats as subjects which were divided into three groups of five subjects: a control group, a pulp tissue extirpation group and an LPS induction followed by extirpation of pulp tissue group. Test samples were collected from the apical field of the mandibular incisor and subsequently examined using immunohistochemical methods.ResultsThere were significant differences in NaV1.7, HSP70 and TNFα expression between the treatment groups. While a marked increase in the expression of HSP70 occurred, both Nav1.7, and TNFα expression decreased significantly.ConclusionExtirpating the dental pulp tissue will induce a more pronounced flare-up response from the molecules of the pulp tissue in vital teeth than those in inflamed vital pulp tissue.     

局麻注射仪用斯康杜尼在恒磨牙牙髓治疗中的应用

目的观察无痛局部麻醉仪注射Scandonest在恒磨牙牙髓治疗中的麻醉效果。方法484例522颗需要牙髓治疗的患牙随机分为2组,分别采用无痛局麻仪注射Scandonest和注射器推注利多卡因后进行开髓,拔髓及根管预备,比较两者在注射时及牙髓治疗中的疼痛程度。结果实验组在注射时及治疗过程中无痛率及有效率皆优于对照组(P<0.01)。结论无痛局麻仪注射Scandonest在恒磨牙牙髓治疗中麻醉效能高,是简单,安全,快速,长效的控制疼痛的方法。     

Pulp testers and pulp testing with particular reference to the use of dry ice

Pulp testing is mandatory before any operative procedures, invaluable in the diagnosis of pain and is an essential adjunct in the interpretation of radiolucent areas. Methods of pulp testing are reviewed and the use of dry ice for this purpose is discussed in detail. Limitations of pulp testing are considered. Vitality tests are of only limited use in traumatized teeth. The results are only qualitative and not quantitative.     

A morphological basis for the levels of pulp extirpation and root c anal obturation (experimental morphological research)

Periapical tissue reaction to root canal filling with zinc-eugenol paste (complete or incomplete filling) was studied in 15 teeth of 5 mongrel dogs after total or subtotal pulp extirpation. Inflammatory reaction developed in all the cases. It was more intensive in cases with total extirpation of the pulp followed by complete or incomplete filling of the root canal than after subtotal extirpation of the pulp followed by root canal filling 1-2 mm below the anatomical apical foramen.     

Radicular cyst associated with a primary molar following pulp therapy: a case report

A radicular cyst arising from the primary second molar and causing displacement of the permanent successor to the lower border of the mandible, with accompanying buccal expansion, was examined clinically and radiographically. Extraction of the primary molar and extirpation of the cyst led to uneventful healing. The primary molar had received pulp treatment with therapeutic agents approximately 1·5 years prior to the patient’s first visit. The relationship between pulp treatment and rapid growth of the radicular cyst is discussed.     

Studies on the surgical approach in vital pulp excision in relation to the root canal cross section]

The authors examined in 38 teeth the condition of the pulp stump after vital extirpation of the pulp in relation to the cross-section of the root canal. They found that the wound conditions could not be evaluated in 17 teeth as there was no pulp stump in the apical region. Relatively favourable conditions were seen in 11 teeth, which was achieved only in case of circular or oval cross-section of the root canal. These findings permit the conclusion that the state of the pulp stump after vital extirpation depends upon the anatomical conditions and the accuracy of the mechanical manipulation.     

Inflammatory and replacement resorption in reimplanted permanent incisor teeth: a study of the characteristics of 84 teeth

Avulsion is a serious injury which can cause damage to some or all of the dental and surrounding tissues. This study examined the profiles of teeth showing inflammatory resorption, in terms of time prior to reimplantation, contamination, pulp extirpation time and period of splinting and compared them to teeth without resorption. There were a total of 71 children in the present study (mean age 9.8 years, range 6-16 years) with a total of 84 reimplanted teeth. Inflammatory resorption was present in 22 teeth. There was a significant relationship between the presence of inflammatory resorption and the time the teeth were dry prior to reimplantation, with a lesser effect for total delay time. There were slightly later pulp extirpation times for teeth with inflammatory resorption, with median delays of 16 and 11 days respectively and increased inflammatory resorption in teeth extirpated at 20 days or later. Replacement resorption was present in 40 teeth. There was a significantly longer splinting time in teeth with replacement resorption and more resorption in teeth splinted for longer than 10 days. It was concluded that pulp extirpation time was not critical unless the delay exceeded 20 days and that splinting time should not exceed 10 days.     

An evaluation of the clinical analgesia/anesthesia efficacy on acute pain using the high frequency neural modulator in various dental settings

The purpose of this study was to evaluate the effectiveness of high frequency neural modulation as a substitute for traditional local anesthesia in various dental procedures. This double-blinded study was done to evaluate patient comfort and degree of satisfaction as well as manageability of pain control by the operator during the dental procedures. Procedures included restorations, tooth extractions, root planing, pulp extirpation, and temporomandibular joint therapy. In the experimental group, favorable responses ranged from 0.0% to 92.8%, depending on the procedures. An overall favorable rating of 71.8% was given by the experimental group, and an overall favorable response of 8.5% was given by the placebo group.     

Pulpal pain diagnosis--a review

Evidence gathered from our studies and the work of others appears to support the presence of two distinct nerve pain pathways in the dental pulp, represented by fast conducting A-delta and slow conducting C-fibers. Each of these types of fibers has different pain characteristics: A-delta fibers evoke a rapid, sharp, lancinating pain reaction, and C-fibers cause a slow, dull, crawling pain. Pain response thresholds vary in different regions of the tooth, and thermal, osmotic, ionic, and electric stimuli involve different mechanisms to provoke nerve excitation of the dental pulp. Evidence also points to the fact that the incidence of pain increases as the histopathosis worsens. On interrogation, patients who manifest severe or referred pain almost always give a previous history of pain in the tooth with the ache. Eighty percent of patients who give a previous history of pain manifest histopathologic evidence of chronic partial pulpitis with partial necrosis, the untreatable category, for which endodontics or extraction is indicated. The other 20% exhibit histopathosis of the pulp with slight inflammation to chronic partial pulpitis without necrosis, a treatable category. Clinically, one can determine the degree of pulp histopathosis by asking the patient about a previous history of pain in the involved tooth. This history of previous pain adds another dimension in diagnosis for the clinician as to whether the painful pulpitis is reversible. This information also aids in referred pain localization.     

Is phantom tooth pain a deafferentation (neuropathic) syndrome?: Part II: Psychosocial considerations

The symptoms of phantom tooth pain are often considered to be of psychological origin by those unfamiliar with its clinical characteristics. Part of the problem is that phantom tooth pain is often confused with atypical facial pain. Extensive literature exists for the latter that suggests a psychological cause. Many studies of atypical facial pain, however, suffer from one or more of four methodologic problems. In the present study, 115 phantom tooth pain cases are compared with a contrast group of 151 facial pain cases and 137 nonpain controls on a variety of personality characteristics. Only one trait personality factor, locus of control, statistically differentiates the three groups. The chief psychological difference of the phantom tooth pain sample compared with the control and contrast groups was higher scores on a measure of demoralization. Demoralization can be interpreted as a consequence as well as an antecedent of the chronic pain state. Evidence for each opinion is presented. Suggestions for obtaining informed consent of prospective endodontic patients are suggested. This study has not demonstrated that phantom tooth pain cases are characterized by a specific premorbid personality.     

Computerized expert system for the diagnosis of pulp-related pain

A major problem in the correct diagnosis of pulpal pain is that the associated clinical signs do not predictably correlate with the underlying pathological process. Using conditional probabilities of various pulp conditions from published data, Bayesian Statistical Inference provides the means for deriving a composite probability of the presence of a disease from a multiple set of symptoms. A computer program that can infer a diagnosis for pulpal pain from any combination of 17 clinical symptoms has been developed. From the data, the program provides the computed relative probabilities of a healthy pulp, a saveable pulp, an unsaveable pulp, and a necrotic pulp being present.     

Angioedema triggered by pulp extirpation��a case report

Background

C1-esterase inhibitor deficiency results in episodes of non-allergic edema of parts of the body. Edema of the face may be triggered by dental therapy.

Case report

We report a case of C1-esterase inhibitor deficiency which was detected in a 42-year-old woman. The patient was completely unaware that she had this disorder or of any related family history, and the patient developed an intense facial angioedema after pulp extirpation of lower premolar tooth.

Discussion

In this case, the diagnosis of angioedema due to C1-esterase inhibitor deficiency was established at a later stage. The differing causes of C1-esterase inhibitor deficiency are briefly discussed and the treatment modalities outlined.     

Periapical tissues microvessels reactivity study after pulp extirpation and on different stages of endodontic treatment

Reaction of the microvessels in the gingival periapical tissues on pulp extirpation was followed by hyperemia development in microcirculatory bed, its expression increased in proportion as parodontal inflammation intensified and further strengthened after root canal filling. Microcirculation normalization in the gingival periapical tissues after endodontic treatment of chronic pulpitis and pulp extirpation as part of endodontic treatment was evident in 1 month in intact parodontium and in 6 months in case of its inflammation.     

Interappointment pain: mechanisms,diagnosis, and treatment

Knowledge on the causes of and the mechanisms behind interappointment pain in endodontics is of utmost importance for the clinician to properly prevent or manage this undesirable condition. The causative factors of interappointment pain encompass mechanical, chemical, and/or microbial injury to the pulp or periradicular tissues, which are induced or exacerbated during root canal treatment. Microorganisms can participate in causation of interappointment pain in the following situations: apical extrusion of debris; incomplete instrumentation leading to changes in the endodontic microbiota or in environmental conditions; and secondary intraradicular infections. Interappointment pain is almost exclusively due to the development of acute inflammation at the periradicular tissues in response to an increase in the intensity of injury coming from the root canal system. When an interappointment emergency occurs, proper diagnosis and active treatment are required for the clinician to succeed in solving the problem. This review focuses on the mechanisms of interappointment pain, with special emphasis placed on the causative agents and the host response to injury that can precipitate pain. In addition, diagnostic measures and treatment approaches to manage interappointment pain are also discussed.     

Inflammatory and replacement resorption in reimplanted permanent incisor teeth: a study of the characteristics of 84 teeth

Kinirons MJ, Boyd DH, Gregg TA. Inflammatory and replacement resorption in reimplanted permanent incisor teeth: a study of the profiles of 84 teeth. Endod Dent Traumatol 1999; 15: 269–272. © Munksgaard, 1999.
Abstract — Avulsion is a serious injury which can cause damage to some or all of the dental and surrounding tissues. This study examined the profiles of teeth showing inflammatory resorption, in terms of time prior to reimplantation, contamination, pulp extirpation time and period of splinting and compared them to teeth without resorption. There were a total of 71 children in the present study (mean age 9.8 years, range 6–16 years) with a total of 84 reimplanted teeth. Inflammatory resorption was present in 22 teeth. There was a significant relationship between the presence of inflammatory resorption and the time the teeth were dry prior to reimplantation, with a lesser effect for total delay time. There were slightly later pulp extirpation times for teeth with inflammatory resorption, with median delays of 16 and 11 days respectively and increased inflammatory resorption in teeth extirpated at 20 days or later. Replacement resorption was present in 40 teeth. There was a significantly longer splinting time in teeth with replacement resorption and more resorption in teeth splinted for longer than 10 days. It was concluded that pulp extirpation time was not critical unless the delay exceeded 20 days and that splinting time should not exceed 10 days.