Clinical Research

What Is the Effect of No Endodontic Debridement

on Postoperative Pain for Symptomatic Teeth
with 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 to
care may present to emergency rooms with pain. They
are often prescribed medications until they can be
treated. There are no studies to show if emergency endodontic debridement is better than giving medications
during this symptomatic period. The purpose of this prospective, randomized study was to compare debridement versus no debridement on postoperative pain in
emergency patients with symptomatic teeth, a pulpal
diagnosis of necrosis, and a periapical radiolucency.
Methods: Ninety-five patients presenting with moderate to severe pain were analyzed. The patients were
randomly divided into 2 groups: group 1 received anesthesia and endodontic debridement, and group 2
received anesthesia but no debridement. At the end of
the appointment, all patients were given ibuprofen/acetaminophen. If needed, they could receive an escape
medication. Patients received a 5-day diary to record
their pain levels and medication taken. Success was
defined as no or mild postoperative pain and no use
of escape medication. Success data were analyzed using
a logistic regression. Results: Both groups had a
decrease in postoperative pain and medication use
over the 5 days. The debridement group had a significantly higher success rate than the no debridement
group. There was no significant difference between
the 2 groups with respect to escape drug use. Conclusions: Patients receiving debridement or no debridement had a decrease in postoperative pain over the
5 days. Debridement resulted in a statistically higher
success rate, but there was no significant difference in
the need for escape medication. (J Endod 2016;-:15)

Key Words
Endodontic debridement, endodontic pain, pulpal
necrosis, symptomatic endodontic patients

From the *Practice Limited to Endodontics, San Antonio,

Texas; and Divisions of Endodontics and Biosciences, The
Ohio State University, Columbus, Ohio.
Address requests for reprints to Dr Melissa Drum, The Ohio
State University, Postle Hall, 305 West 12th Avenue, Columbus,
OH 43210. E-mail address: drum.13@osu.edu
0099-2399/$ - see front matter
Copyright 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.12.001

JOE Volume -, Number -, - 2016

ymptomatic teeth with a pulpal diagnosis of necrosis are frequently treated in a

specialty endodontic practice (15). 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 to
hospital emergency rooms with dental pain and are often prescribed pain
medication and antibiotics and referred to a dentist for evaluation and treatment
(6). According to the National Hospital Ambulatory Medical Care Survey, dental
emergency room visits in the United States increased by 1 million from 2000 to
2010 (7). A community dental health coordinator stated that she sees patients daily
who have waited too long for dental treatment. Often, theyve visited the emergency
room and received antibiotics as a temporary treatment but havent followed up with
a dentist to completely resolve their problem (7). A retrospective analysis of patients admitted to the emergency room with a diagnosis of periapical abscess
showed that over 9 years there were 61,439 hospitalizations because of periapical
abscess in the United States (8). In addition, the number of hospitalizations
increased 41% from 2000 to 2008 (8). A study assessed the prevalence and costs
associated with emergency department visits in 2006 and found there were 403,149
emergency department visits in a year associated with pulpal and periapical disease
totaling $163,692,957 in hospital charges (9).
Dental emergency room visits were evaluated and described from 1997 to 2000 by
Lewis et al (6). There were 2.95 million dental emergency department visits in total, and
at least 1 prescription was given in more than 80% of visits; antibiotics were prescribed
in 49% of visits, whereas 72% of patients received analgesics (38% received a narcotic
prescription). The dental emergency department visits were more likely to occur on the
weekend when many dental offices were not open (6).
Although many emergency room physicians recommend more definitive
follow-up care, it is not known how many of these patients follow through with
this recommendation. Dental-related emergency room visits from 5 major hospital
systems in Minneapolis over 1 year showed that over 10,000 visits were related to
dental problems (10). Of these 10,000 visits, 2,499 were second or additional
repeat visits for a dental problem. Therefore, about 20% of the dental-related
emergency room visits were repeat visits. A major concern with the treatment
of dental problems in a hospital setting is the lack of follow-up and definitive
dental treatment (1012).
Although it is known that patients are commonly prescribed antibiotics and pain
medication for dental pain in the emergency room, it is not known what happens
to these patients once they leave the hospital setting (6). If they do not seek
immediate dental treatment, what is the amount and duration of postoperative
pain they experience?
There are currently no studies to show if initial endodontic debridement is
better than just placing the emergency patient on medications for pain relief during
this symptomatic period. The purpose of this prospective randomized study was to
compare the effects of endodontic debridement versus no endodontic debridement
on postoperative pain in emergency patients with symptomatic teeth, a pulpal diagnosis
of necrosis, and a periapical radiolucency.

Symptomatic Teeth with Pulpal Necrosis

Clinical Research
Materials and Methods
One hundred eight adult patients presenting for emergency treatment initially participated in this study. All subjects were in good physical condition as determined by a written questionnaire and oral
questioning. Each patient was required to be 18 years or older and
be in good health with an American Society of Anesthesiologists classification of I or II. Patients were excluded from the study if they were taking chronic pain medications; if they were allergic to local anesthetics,
ibuprofen, acetaminophen, or codeine; if they reported a history of
gastrointestinal problems, angioedema, or bronchospastic activity to
aspirin or other nonsteroidal anti-inflammatory drugs; or if they were
unable to give informed consent. In addition, prisoners and mentally
disabled patients were excluded. All female subjects were questioned
regarding pregnancy or suspected pregnancy. None were allowed to
participate if they were pregnant, suspected of being pregnant, or
were trying to conceive. Approval for this study was obtained from
the universitys human subjects review committee, and written consent
was obtained from each participant.
Each patient had a distinct radiolucency at the apex of a symptomatic tooth and a diagnosis of pulpal necrosis as shown by a negative
response to an electric pulp tester (Analytic Technology Corp, Redmond, WA) and Endo-Ice (Hygenic Corp, Akron, OH). Patients were
also required to have no or mild swelling and no draining sinus tract.
The patients temperature was taken orally using the SureTemp digital
thermometer (Welch Allyn Ltd, Navan, CO), and any patient with a temperature above 100 F was excluded from participation.
Each patient rated his or her initial pain on a Heft-Parker visual
analog scale (VAS) (13). The VAS was divided into 4 categories as
described previously (5). To qualify for the study, patients had to present with moderate to severe pain. Each patient also completed the
Corah Dental Anxiety Scale questionnaire (14).
Before the experiment, the 2 regimens (debridement or no
debridement) were randomly assigned 5-digit numbers from a random
number table. The number assignment determined whether debridement or no debridement was performed for each patient. Only the
random numbers were recorded on the data collection sheet to maintain blinding of the experiment.
Each patient was anesthetized with 2 cartridges of 2% lidocaine
with 1:100,000 epinephrine (Xylocaine; AstraZeneca LP, Dentsply,
York, PA) administered by an inferior alveolar nerve block or maxillary
infiltration. Patients in the debridement group had the affected tooth
isolated with a rubber dam and endodontic debridement performed using 3% sodium hypochlorite irrigation and hand and rotary files. The
canals were prepared to a minimum size of a 30/.04 or 40/.04 depending on the tooth and canal treated. The canals were dried with paper
points, and calcium hydroxide (Multi-Cal; Pulpdent Corp, Watertown,
MA) was placed as an intracanal medicament. The teeth were temporized with Cavit (Cavit G; 3M ESPE, Seefeld, Germany), and the patients
were scheduled for root canal completion. The senior author (R.S.)
performed all endodontic treatment.
For the no debridement group, local anesthesia was administered
using 2 cartridges of 2% lidocaine with 1:100,000 epinephrine as
described previously. This completed the treatment phase.
If patients presented to the clinic already taking an antibiotic, they
were instructed to finish their current regimen if the antibiotic and
dosage were clinically appropriate. Patients who were not on antibiotics
or were not prescribed an appropriate antibiotic regimen received a
prescription for an antibiotic (500 mg penicillin; if allergic, 300 mg
clindamycin) to be taken every 6 hours until gone. Antibiotics were
administered because a number of presenting patients were already
on antibiotics, and we wanted to eliminate this variable from the study.

Sebastian et al.

TABLE 1. Preoperative Variables for the Debridement and No Debridement

Groups
Variable

Debridement

No
debridement

36  12
20 female,
26 male
119  27
9

39  17
25 female,
24 male
120  27
9

7% (3/46)
26% (12/46)
67% (31/46)

12% (6/49)
16% (8/49)
71% (35/49)

52% (24/46)
48% (22/46)

51% (25/49)
49% (24/49)

Age (y)
Sex
Presenting pain
Corah anxiety
(median)
Tooth location
Anterior
Premolar
Molar
Jaw
Maxilla
Mandible

P value*
.3666
.4616
.9088
.3952
.3914

.9105

*There were no significant differences between the 2 groups.

Mean  standard deviation.

Mean  standard deviation, Heft-Parker VAS ratings.

The patients in both groups were also given a 5-day supply of

600 mg ibuprofen (Amneal Pharma of NY, Hauppage, NY) with instructions to take 1 tablet every 6 hours as needed for pain and a 5-day supply of 500 mg acetaminophen (Amneal Pharma of NY) with
instructions to take 2 tablets every 6 hours as needed for pain. The
pain medications were placed in separate amber pill bottles, but the
patient was instructed to take both medications at the same time.
The bottles were affixed with different colored labels (1 color for
ibuprofen and another color for acetaminophen) containing the
drug information including the name, dose, quantity, and medication
instructions. The patients were instructed not to take any other pain or
antibiotic medications. If the ibuprofen/acetaminophen was not managing their pain, the patients were instructed to call an assigned cell
phone number that was carried by the investigator. After speaking
with the investigator, if an escape medication was needed, hydrocodone/acetaminophen (5/500 mg, 16 tablets, 12 tablets every 6 hours)
was prescribed. Because of the changes to the drug formulation during
data collection, some patients received hydrocodone/acetaminophen
5/325 or hydrocodone/acetaminophen 5/300 based on pharmacy

TABLE 2. Logistic Regression Summary for Treatment Success

Type III tests of fixed effects
Effect

Num
DF

Den
DF

Chi-square

Pr >
Chi-square

Group
Day
Group by day
Sex
Group by sex
Sex by day
Group by sex by day

1
5
5
1
1
5
5

546
546
546
546
546
546
546

5.09
32.93
4.64
10.57
1.27
3.74
5.72

.0241
<.0001
.4608
.0011
.2593
.5879
.334

Odds ratio estimates

Group (debridement vs no
debridement)
Sex (female vs male)

95%
confidence
limits

Estimate

DF

1.519

546

1.055

2.185

0.548

546

0.38

0.788

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Clinical Research
TABLE 3. Percentages and Discomfort Ratings of Postoperative Pain for the Debridement and No Debridement Groups (excluding patients who took narcotics)
Group
Day 0*
Debridement
No debridement
Day 1
Debridement
No debridement
Day 2
Debridement
No debridement
Day 3
Debridement
No debridement
Day 4
Debridement
No debridement
Day 5
Debridement
No debridement

None

Mild

Moderate

Severe

Median

P value

3% (1/37)
9% (4/42)

35% (13/37)
38% (16/42)

54% (20/37)
38% (16/42)

8% (3/37)
14% (6/42)

58.0
57.5

.8587

8% (3/36)
7% (3/43)

42% (15/36)
26% (11/43)

47% (17/36)
60% (26/43)

3% (1/36)
7% (3/43)

52.0
59.0

.0982

4% (2/45)
8% (4/47)

49% (22/45)
32% (15/47)

42% (19/45)
49% (23/47)

4% (2/45)
11% (5/47)

36.0
58.0

.0975

27% (12/44)
15% (7/47)

39% (17/44)
40% (19/47)

32% (14/44)
38% (18/47)

2% (1/44)
6% (3/47)

22.0
46.0

.0496

23% (10/44)
15% (7/47)

50% (22/44)
36% (17/47)

27% (12/44)
42% (20/47)

0% (0/44)
6% (3/47)

20.5
45.5

.0170

39% (17/44)
19% (8/43)

39% (17/44)
44% (19/43)

23% (10/44)
30% (13/43)

0% (0/44)
7% (3/43)

3.0
38.0

.0060

*Night of treatment when local anesthesia wore off.

availability. The patient was instructed to stop taking the ibuprofen and
acetaminophen once starting the escape medication to avoid exceeding
recommended drug dosing. The patient was seen emergently in the
clinic if the need arose.
Patients received a diary for the day of the appointment and 5 days
postoperatively to record any pain they were having and the amount of
pain (ibuprofen/acetaminophen combination or escape) medication
taken. Patients recorded the type and number of pain medications taken
during the time period between the completion of the endodontic procedure and before going to bed the night of the appointment after the
local anesthesia had worn off. For the next 5 days, patients recorded
pain on the Heft-Parker VAS and the type and number of pain medications taken each day. Patients were asked to return all unused medications upon completion of the study to verify diary input. The patients
assigned to the no debridement group were scheduled for endodontic
treatment 5 days later or at their earliest convenience. Success
was defined as none or mild postoperative pain and no use of narcotic
medications. Overall success was calculated for the debridement and no
debridement groups.
The data from this study were statistically analyzed. Comparisons
between the debridement and no debridement groups for age and initial
pain ratings were made using the randomization test. Comparisons in
sex and jaw were analyzed via chi-square tests. Differences in tooth
type were analyzed using the Fisher exact test. Corah anxiety ratings
were assessed using the Mann-Whitney-Wilcoxon test.
Between-group differences in success were evaluated using a
repeated measures logistic regression with group, day, and sex as the
independent variables. A mixed model analysis of variance with postoperative day, patient sex, and treatment group as the independent variables was used to evaluate total analgesic use. Tooth type and jaw

Figure 1. Postoperative pain by group and day.

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were included as random variables. Post hoc testing was performed using the Tukey-Kramer procedure. Because the postoperative pain values
were not normally distributed, they were analyzed nonparametrically
using multiple randomization tests with the P values adjusted using
the step-down Bonferroni method of Holm. Comparisons were considered significant at P < .05. For VAS pain scores, assuming a standard
deviation of 50.3 (5), a difference of 30 mm could be detected
with a power of 0.80 with 45 patients per group.

Results
A total of 108 subjects were enrolled in this study. Thirteen subjects were disqualified for the following reasons: 1 because of a fracture
detected upon endodontic access, 11 for not returning postoperative
surveys, and 1 for not disclosing the use of Percocet daily for chronic
back pain. Ultimately, 10 patients were disqualified from the debridement group, and 3 patients were disqualified from the no debridement
group. Therefore, the total number of subjects analyzed was 46 in the
debridement group and 49 in the no debridement group.
TABLE 4. Mean Number of the Combination Medications Taken (excludes
patients who took narcotics)
Group
Day 0*
Debridement
Nondebridement
Day 1
Debridement
Nondebridement
Day 2
Debridement
Nondebridement
Day 3
Debridement
Nondebridement
Day 4
Debridement
Nondebridement
Day 5
Debridement
Nondebridement

Number of
patients

Mean number
tablets

37
43

4.8  2.7
4.4  3.1

1.0000

37
43

6.3  3.8
7.8  3.9

.7874

37
43

4.9  3.8
6.8  4.0

.4742

37
43

3.6  3.6
5.9  4.1

.1996

37
43

2.9  4.0
4.6  3.6

.6703

37
40

2.2  3.9
4.2  3.7

.4562

P value

*Night of treatment when local anesthesia wore off.

Symptomatic Teeth with Pulpal Necrosis

Clinical Research

Figure 2. Combination ibuprofen/acetaminophen use by day.

Table 1 shows the preoperative variables. There were no statistically 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, 1.0552.185 for debridement vs no
debridement), sex (odds ratio = 0.548; 95% confidence interval,
0.3800.788 for females vs males), and day. All interaction effects
were not significant (P > .259).
Table 3 shows pain by day for the debridement and no debridement groups. Moderate to severe pain was experienced by 52%62%
of the patients the night of the treatment and 50%67% of the patients
on day 1, with the pain ratings decreasing over the next 4 days. Significantly lower pain values were noted for the debridement group for days
3 through 5. Figure 1 shows the postoperative pain ratings over the 5
days.
Table 4 and Figure 2 show the mean number of combination
ibuprofen/acetaminophen tablets taken by day for the debridement
and no debridement groups. The highest number of medication use
was 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 the
no debridement group took escape medications with no significant
(P = .3218) difference between the groups (Fig. 3).

Discussion
Differences in the preoperative variables would be minimized
because no statistically significant differences were shown between
groups (Table 1). The presenting initial moderate pain level
(Table 1) is representative of emergency patients with symptomatic
teeth, a pulpal diagnosis of necrosis, and a periapical radiolucency as
shown by Wells et al (5). Because most subjects in both groups reported
low to moderate Corah scores (Table 1), anxiety may not have played a
large role in influencing the pain associated with debridement or no
debridement. The influence of tooth location was minimized because
the 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 the
tooth at the emergency visit. Endodontists would be likely to perform
complete debridement because of their advanced training and experience. However, inexperienced operators may not be able to perform
complete debridement at the emergency visit.
The patients in the no debridement group did not get worse over
the 5 days, indicating that analgesics may help these symptomatic patients presenting with a necrotic pulp and associated periapical radiolucency. The use of antibiotics would not be expected to help because
the 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 or

acute apical abscesses (3, 15). If the patient is immunocompromised
or has significant medical conditions, perhaps complete debridement
would be indicated versus no debridement.
Although pain was reduced from presenting pain levels, moderate to severe pain levels were still reported by 52%62% of the
patients the night of the treatment and 50%67% of the patients
on day 1 (Table 3). Most medication usage was in the first several
days and decreased over the 5 days paralleling the decreasing pain
(Table 3, Fig. 2). The decrease in tooth pain over the 5 days is most
likely attributable to the natural course of the disease process for the
clinical condition of a symptomatic tooth with a necrotic pulp and an
associated periapical radiolucency. Other authors (15) showed that
the majority of patients started to improve regardless of drug or
active treatment protocols on the third postoperative day. Our
results confirm these observations. Patients improved even without
emergency debridement.
Twenty percent (9/46) of patients in the debridement group
and 12% (6 of 49) in the no debridement group took escape medications with no significant (P = .3218) difference between the
groups (Fig. 3). Wells et al (5) found 20% of patients used escape
medication (Vicodin) when the combination of ibuprofen and acetaminophen was ineffective for pain control in symptomatic patients
with a necrotic pulp and an associated periapical radiolucency who
were experiencing moderate to severe preoperative pain. Therefore, the combination of ibuprofen and acetaminophen would
not be completely effective for controlling postoperative pain in
these patients. However, even with no debridement, most patients
did not require escape medication. Symptom improvement without
treatment and lack of narcotic use may be important in certain
clinical scenarios.

Figure 3. Escape drug use.

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Clinical Research
We concluded patients receiving debridement or no debridement
had a decrease in postoperative pain and medication use over the
5 days. Complete endodontic debridement resulted in a statistically
higher 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.

Acknowledgments
The authors deny any conflicts of interest related to this study.

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Symptomatic Teeth with Pulpal Necrosis