JOURNAL OF ENDODONTICS [ VOL 8, NO 8, AUGUST 1982

Incidence of postoperative pain after one-appointment

endodontic treatment of asymptomatic pulpal necrosis
in single-rooted teeth

John Martin M u l h e r n , B Dent Sc, MSD; S a m u e l S Patterson, DDS, MSD;

Carl W. N e w t o n , DDS, MSD; a n d A. M i c h a e l R i n g e l , DDS, MSD

Sixty s i n g l e - r o o t e d t e e t h w e r e e n d o d o n t i c a l l y t r e a t e d b y t w o
p o s t g r a d u a t e s t u d e n t s for a s y m p t o m a t i c p u l p a l necrosis. T h i r t y w e r e
t r e a t e d in a single visit each, a n d a c o n t r o l g r o u p of 30 w e r e t r e a t e d
in t h r e e visits each. Clinical a n d r a d i o g r a p h i c e v a l u a t i o n s w e r e
m a d e . A subjective q u e s t i o n n a i r e w a s u s e d to r e c o r d p a i n experience.
N o significant d i f f e r e n c e in t h e i n c i d e n c e of p a i n existed b e t w e e n
t h e single- a n d multi-visit g r o u p s .

A one-visit root canal treatment is Taintor and Ross 9 attributed the pain after the one-appointment treat-
attractive to a patient because it saves relatively rare instances of postobtura- ment of painful pulpitis without apical
time and would probably reduce cost. tion pain either to periapical irritation involvement seen radiographically.
In addition, one visit is less stressful to by material extruded through the Although no significant difference
the anxious patient. apex, poor coronal seal, high occlu- occurred in the incidence of pain
Several studies 16 have considered sion, or cracked tooth, or to such between the one-appointment and
this mode of root canal treatment, and diverse causes as adjacent tooth multiappointment treatments, the se-
in 1980, Landers and Calhoun 7 involvement, or an interradicular peri- verity did seem to be greater in the
reported that according to a survey of odontal abscess. Most pain according one-appointment cases.
50 postgraduate endodontic programs to their report occurs between appoint- This study investigated the inci-
in the United States, a large percent- ments, after the tooth has been opened, dence of postoperative pain after one-
age of these programs are teaching and but before it has been obturated. As appointment nonsurgical endodontic
practicing one-appointment therapy causes of preobturation pain, they treatment of asymptomatic pulpal
for some endodontic problems. Most cited overlooked root canals, incom- necrosis in single-rooted teeth that had
program directors have said there has pletely instrumented root canals, over- no sinus tracts.
been little difference between single- instrumentation, overmedication, root
and multi-appointment therapy with perforation, cracked teeth, and exu- METHODS AND
respect to postoperative flare-ups, suc- dates to the apex. MATERIALS
cessful healing, and patient accep- In an investigation of the ability of
tance. trephination to prevent or relieve pain Identification a n d selection of
Morse s has stated that, "in non-vital in endodontically treated teeth, Peters 5
subjects
cases, once the canals are clean, concluded that whether the root canal
smooth, tapered, and dry and the tooth is filled after one or after two appoint- Patients studied were those requir-
is symptomless, then obturation can be ments is not highly significant in rela- ing endodontic therapy in asymptom-
done. This may be the first, second, tion to pain. atic, mature single-rooted teeth with
third or fourth visit." Flatley 1~ investigated postoperative

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 JOURNAL OF ENDODONTICS I VOL 8, NO 8, AUGUST 1982

necrotic pulps. Excluded from this solution. Root canal lengths were questionnaire for each visit, and a
study were patients with medically recorded, using either a size 10 or 15 clinical examination was conducted
compromising conditions, or exposure file. Initial incremental preparation of one week after all treatment was com-
to factors that might interfere with the the root canal was performed. After plete. The postoperative clinical exam-
normal inflammatory response, such drying the canals with paper points, a ination consisted of assessing the pres-
as use of corticosteroid or other anti- dry pledget of cotton was inserted in ence of either swelling or tenderness to
inflammatory drugs. Individuals who the canals of those teeth treated in percussion.
had been on recent or active antibiotic multiple appointments, and they were
therapy (other than as a direct result of sealed with a double cement system of Statistical analysis
the tooth being treated) were also Cavit G and zinc oxyphosphate
excluded. cement in the coronal access cavity. The data were statistically analyzed
Sixty maxillary and mandibular At the second visit, root canal prep- by the Chi-square test to determine
single-rooted teeth were treated by two aration was completed; then the seal- any significant differences between the
graduate endodontic students. The ing process was repeated. At the third single- and multiple-appointment pro-
teeth were randomly assigned to group appointment, the gutta-percha master cedures concerning incidence and
1, the experimental group in which 30 points were fitted and verified radio- severity of pain (Table 1). Other vari-
teeth were treated in a single visit, or graphically. The root canal was thor- ables that were analyzed were:
group 2, the control group in which 30 oughly dried with paper points after medication; presence or absence of
teeth were treated in three visits. irrigation with 95% alcohol. Gutta- radiolucent area periapically; maxil-
Patients in the experimental group percha was sealed with Kerr Tubli- lary or mandibular tooth position;
received free treatment, whereas those seal, using a lateral condensation tech- result of aerobic culture; maximum
in the control group were charged the nique. A temporary double-seal was file size used at the first appointment;
usual clinic fee for treatment. placed and a final radiograph was level of root canal filling with respect
made. All patients were routinely to radiographic apex; age; sex; race;
Procedures advised to expect some tooth sensitivity and canal humidity.
for 24 to 48 hours after each appoint-
The endodontic treatment was per- ment. Provision was made available RESULTS
formed in the following manner for for care of any exacerbations that
group 2 (control): might occur between appointments. Patients' ages ranged from 13 to 75
No local anesthesia was administered. For teeth in group 1, repetition of years, with approximately equal dis-
The tooth was isolated with rubber sealing treatment on successive visits tribution according to gender. Eight
dam and swabbed with povidone- did not apply as all treatment was patients experienced pain in the sin-
iodine, USP. All decay and carious completed in a single visit. gle-visit treatment and 12 in the multi-
debris were removed from the coronal visit treatment. There was no signifi-
aspects of the tooth; the occlusion was M e t h o d s for o b t a i n i n g a n d cant difference in the occurrence of
relieved; and access was obtained. A pain between the one-appointment
recording observations
sample of the root canal contents was and multi-appointment treatment
obtained on a paper point for aerobic Each patient in the single-visit groups (Table 2).
culture (Brain Heart Infusion) with group (group 1) was given a question- Medications taken for pain were
0.1% agar. The root canal was irri- naire to complete 48 hours after treat- aspirin (the most common), Tylenol,
gated with 2.5% sodium hypochlorite ment. A clinical examination was con- Tylenon 3, Synalgos-DC, and Darvo-
solution. The preoperative radiograph ducted one week postoperatively, and cet. Neither of the clinicians prescribed
was measured for canal length deter- the patient was asked to complete a these medications, and none of the
mination. A fine barbed broach was similar questionnaire designed to sep- patients indicated that they had sought
used for thorough removal of pulpal arate "a difference in feeling" from analgesic prescriptions because of the
debris from each root canal; and the other gradients of pain. 1~ treatment. The medications taken may
apical portion of the root canal was Patients with multivisit treatments have been simply those most readily
cleaned with a size 10 file and frequent (group 2) were asked to complete a available to the patients. Only one
irrigation with sodium hypochlorite prescription was written and that was

371
 JOURNAL OF ENDODONTICS I V O L 8, N O 8, A U G U S T 1982

iiiiii!:i!i;i
84184184184184184184
~i~iii[~ii!i i !i~!i~
iii~>~:~. . . . . :~~)51]]11:~iii.
.... ;.""."~ ~ ii~O(! (i;"] i!ii~ii[Y

x,bJe ; single- and multiple appointment endodontic treatment of patients reporting pain.
Single aopointmen/ Multiple Appointment
With pain Without pain With pain Without pain
Factors no. % no. % no. % no. %
26.7 22 73.3 12 40 18 60

11 36.7 2 6.7 12 40
11 36.7 10 33.3 6 20

~!;~ '!,i,d !~( 9 , [!

23;3 14 46.7 6 20 15 50
3:3 8 26.7 6 20 2 6.
_ ~ - 0 1 3

23.3 1
50 I1

63.3 7 23;3 12 40

.....i!iii~ili!!!!i84184184
!:::~i;i) !! ~ w 84
!i!i~!~i~~:~;!i!iiiiiiiiiii~iii!~i!iiiiililil
;:;~: .~::::~:~
......... 13 43 ~iiiiiili i i! ii] ii! i ::: 6.0 ..........
i:;~;i==:~!:
i6.~il ~;il;iii ~3 ;~:~;;:!i!ii~!i!ii!iik!i!iii!ili!!ili!fi~i!
!!i iii!i!~ii~ii!iiiii!iii!i~];i~!ii;i;!i;Oi!i~:il;3o ....... i:ii

i67

i i i i i ;!ii i!!i;"~L
i/~i
/il;i~!i;!i!i:i!i(ili!!i;i!ii!:i!:i::~iii!i;i!;]!~;i!~;;]G!iii:!iQ:]!(i!;:!!i;?
. . . . . . 584
!!iii!90 [i:! ! i!ii!!i !i:i[iii! i! ii!]iii!!i[ ii[ iii!iii i !!ii !] i16.7 , ii;!iiiii!i!iiiiiiiiii
i !i i LLii ~! ............!i!ii!i!ii!i!i!iii!!!!i!iiiiiiiii!iii!

ii!!ji~'L!!!i!i iiiiiiiiiji!iii!iiiiiiiii!iii : :

372
 JOURNAL OF ENDODONTICS I VOL 8, NO 8, AUGUST 1982

tin e x p e r i e n c e

~ut pain
Expected Total
(19.3) 29
(20.7) 31
40 60

for penicillin for a patient with an In the experimental group, the eight of pain per dental manipulation,
elevated temperature. This patient, patients who reported pain described a regardless of group.
along with those who took the stronger total of ten incidents of pain. Seven of It was significant that two thirds of
analgesics (Tylenol 3, Synalgos-DC, these patients reported pain on the the patients treated had no pain.
and Darvocet), and the two patients 48-hour postobturation questionnaire.
who had detectable swelling, were all Two of them still reported pain at DISCUSSION
from the experimental group. Al- one-week postobturation, whereas
though this group of patients may only one patient who had reported no The results of this study show that
appear to be substantially different pain at 48 hours did report pain on the there is no significant difference in the
from the other patients who experi- one-week postobturation question- incidence of postoperative pain be-
enced pain, a Yates correction for naire. tween one-visit and multi-visit endo-
small numbers in cells showed no In the control group, 12 patients dontic treatment of asymptomatic
significant differences. This was also reported pain, for a total of 19 inci- pulpal necrosis. Although a third of all
true of the distribution of the patients' dents. Eight incidents of pain were the treated patients experienced pain,
experience of pain according to swell- reported 48 hours after the first visit; no factor studied clearly indicated the
ing alone. three were reported 48 hours after the cause. If we treat a tooth on three
Clinically and radiographically, the second visit (only one of these patients occasions rather than on one, we can
apical terminus of the root canal filling had previously reported pain); and six expect the chances of at least one
seemed to have no effect on the inci- incidents of pain were reported 48 incident of pain to increase three times.
dence of pain. In recording level of hours after the obturation appoint- The incidence of pain in females in
filling, no distinction was made ment (of these, two patients had not this study was significantly higher
between sealer or gutta-percha. The previously reported pain). On the one- than in males, though only in the
range of fillings was 2 + mm from the week postobturation questionnaire, control group (Table 3). It may be that
radiographic apex. only two incidents of pain were re- females experience increased anxiety
While a significant difference was ported, both in patients who had when treatment is prolonged as it was
noticed in the distribution of pain reported five days before obturation in the control group. The actual num-
according to gender (Table 3), this but not immediately after the first ber of patients experiencing pain was
difference was confined to the control visit. also greater in the control group. The
group., Only two of the 14 males in In both groups, the incidence of pain fact that these patients did pay a
that group reported pain compared at one-week postobturation was low, nominal fee for their treatment may
with ten of the 16 females. 3:30 (experimental) and 2:30 (con- have caused them to be more fastidious
Age, race, tooth position, periapical trol). At 48-hours postobturation, the and to express discomfort more readily
radiolucent areas, results of bacterial incidence of pain was 7:30 (experi- than those from the experimental
culture, canal humidity, and amount mental) and 6:30 (control) (Table 1). group who paid no fee.
of initial filing did not appear to As Table 4 shows, there was no If the strength of analgesic taken by
influence the pain experience. significant difference in the incidence the patients directly reflected the

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 JOURNAL OF ENDODONTICS [ VOL 8, NO 8, AUGUST 1982

to the pain experience as well as the

Table 4 9 Distribution of dental manipulations high incidence of filling material
according to incidence of pain.* extrusion (Table 1). Twenty-three of
Incidence Control group Experimental group 60 cases treated showed periapieal
extrusion of sealer or gutta-percha, or
of pain Observed Expected Observed Expected Total
both. The lack of resistance offered by
Pain 17 (18) 7 (6) 24
No pain 73 (72) 23 (24) 96 a damaged periodontal ligament and
Total 90 90 30 30 120 lamina dura could account for the ease
of overfilling. In teeth with necrotic
*For X2 = 0.28; D F = 1; .7 > P > . 5 .
pulps, it is not unusual to have some
periapical resorption of the apex,
which could result in a wider than
normal apical constriction, also
severity of pain experienced, the post- been balanced by pain caused by tech- increasing the tendency on the opera-
operative pain in the experimental nical difficulties in maxillary lateral tor's part to overfill. We thought these
group could be considered more severe teeth, which frequently have dilac- teeth had not been overinstrumented
in nature. It could also reflect accessi- crated roots. during preparation because a stan-
bility of controlled substances for self- The finding that a periapical radio- dardized technique had been main-
medication. However, because these lucent area did not have a significant tained in each case.
were, in fact, self-medications, no con- relationship to pain was not unex- Although past endodontic experi-
clusions can be made. However, the pected, considering the difficulty in ence was not recorded, it may welt
fact that the patient who required the radiographic interpretation of a peria- have been a factor in pain experience.
systemic antibiotic and the two pical radiolucent area. TM Likewise, O'Keefe 2 showed the relationship of
patients with detectable swelling were considering the recent literature on the past endodontic experience with less
also from the experimental group sup- culturing of root canal contents, it is severe pain before treatment. He said
ports the hypothesis that postoperative not surprising that this study showed patient's previous experience might
inflammation after the single visit is no correlation between pain experi- represent earlier detection of a prob-
more severe. ence and the results of bacteriologic lem by either the patient or the dentist,
The finding that pain did not differ cultures. What is not as easily or it might indicate the patient's most
in patients younger or older than 21 explained is the finding that teeth that positive attitude toward treatment.
years old agreed with those of Clem 6 had obviously wet canals on opening Being asked to report pain or being
and Maddox and others" but not with showed not correlation with the pain told to expect discomfort might predis-
the results of Seltzer and others, a2 or experience. Because the accumulation pose the patient to an expected symp-
O'Keefe. 2 of tissue fluid is inherent in inflamma- tom.
Race was not a factor in the pain tion, it was assumed that teeth with Initial file length was not evaluated
experience in this study. The study wet canals could not be considered in this study. It is quite possible that
population was taken from one geo- quite as clinically asymptomatic as irritation of periapical tissue caused by
graphic area. This lack of diversity teeth having dry root canals as detected an initially long file was related to the
might be explained by the findings of on opening. incidence of pain.
Milgram, ~3who showed a relationship The lack of correlation between Of great concern to endodontic ther-
between nationality and conformity in pain and the amount of initial filing apy is the overall high incidence
which culture may be more significant may indicate decreased importance of (33.3%) of discomfort reported in this
in experiencing pain than simple dif- apically extruded debris as a cause of study. The figure is within the range
ferences of race. discomfort in these necrotic cases. of other studies 2'3'5'631 with reported
Maxillary or mandibular arch tooth Periapical resorption of hard tissues incidences ranging from 16% to 54%.
position was not a factor. Pain caused may permit a comfortable adaptation In the current study, when pain did
by any technical difficulties experi- of any extruded material. This may occur it was within 48 hours of an
enced in mandibular incisors, which also explain the lack of significance the operative procedure. Provided no fur-
frequently have two canals, may have level of filling material has in relation ther manipulation took place, the inci-

374
 J O U R N A L OF E N D O D O N T I C S ] VOL 8, NO 8, A U G U S T 1982

dence of pain dropped by more than area, results of aerobic culture of canal References
50% within one week. Although none contents on opening tooth, canal 1. Fox, J. and others. Incidence of pain
of the patients found the pain to be following one-visit endodontic treatment. Oral
humidity, or amount of initial filing.
Surg 30:123-130, 1970.
severe, every effort should be made by Although a correlation was obtained 2. O'Keefe, E.M. Pain in endodontie thera-
clinicians to minimize any discom- between gender and pain experience in py: preliminary report. J Endod 2:315-319,
fort. the control group (female patients 1976.
We thought that the multi-visit reported more pain), this finding is 3. Sohanofl, W. A comparative study of the
schedule provided some advantages in single visit and multiple visit endodontic proce-
viewed with some doubt.
dure. J Endod 4:278-281, 1978.
terms of assessing the health of the The occurrence of pain proved to be 4. Ashkenaz, P.J. One-visit endodontics: a
periapical tissues, becoming familiar unpredictable. preliminary report. Dept Surv 55:62-67, 1979.
with the canal morphology, and gain- The eventual success or failure of 5. Peters, D.D. Evaluation of prophylactic
ing easy access to treatment of the the treatment is of greater concern to alveolar trephination to avoid pain. J Endod
periapical tissues, if necessary, which 6:518-526, 1980.
the patient and dentist than any tran-
6. Clem, W.H. Posttreatment endodontic
might be significant in the eventual sient discomfort associated with treat- pain. JADA 81:1166-1170, 1970.
success of the root canal treatment. ment. Therefore, before advocating the 7. Landers, R.R., and Calhoun, R.L. One
Multiple-appointment treatment may routine use of single-visit treatment of appointment endodontic therapy. An opinion
also be more effective in the control of asymptomatic pulpal necrosis, long- survey. J Endod 6:799-801, 1980.
clinically significant bacterial contami- 8. Morse, D.R. Clinical endodontology.
term studies of success or failure
Springfield, Ill, Charles C Thomas, 1974,
nation with intracanal medications should be evaluated. p 466.
and irrigation solutions. 15 However, 9. Taintor, J.F., and Ross, P.N. Endodontic
multiple-appointment therapy may This research was aided by a Grant-in-Aid of posttreatment pain. Dent Surv 54:52-55, 1978.
actually increase chances of contami- Research from the Endowment and Memorial 10. Flatley, C.J. Incidence of postoperative
nation during or between visits by the Foundation of the American Association of En- pain following one-appointment treatment of
dodontists. painful pulpitis without apical radiographic
added risk of leakage around the rub- involvement. Thesis. Indianapolis Indiana Uni-
ber dam or through the sealing materi- versity School of Dentistry, 1975.
al: The authors thank Professor Paul Barton, 11. Maddox, D.L.; Walton, R.E.; and Davis,
Indiana University School of Dentistry, for
C.O. Incidence of post treatment pain related to
editorial assistance.
medicaments and other factors. J Endod 3:447-
SUMMARY AND
452, 1977.
CONCLUSIONS Dr. Mulhern is in private practice, Winnipeg, 12. Seltzer, S.; Bender, I.B.; Ehrenreich, J.
Manitoba, Canada; Dr. Patterson is chairman, Incidence and duration of pain following endo-
In this study, there was no differ- department of endodontics, Indiana University dontic therapy. Oral Surg 14:74-82, 1961.
School of Dentistry, Indianapolis; Dr. Newton 13. Milgram, S. Nationality and conformity.
ence in the incidence of pain whether is associate professor, department of endodon- Sci Am 205:45-5l, 1961.
treatment was performed on a single- tics, Indiana University School of Dentistry, 14. Goldman, M.; Pearson, A.; and Darzen-
or multi-visit basis. Pain did not Indianapolis; and Dr. Ringel is in private prac- ta, N. Endodontic success. Who's reading the
tice, Mississauga, Ontario, Canada. Request for
appear to be influenced by any of the reprints may be directed to Dr. Samuel S
radiograph? Oral Surg 33:432-437, 1972.
following: age, race, tooth position, 15. Ringel, A.M. and others. A clinical study
Patterson, Indiana University School of Dentist-
ry, 1121 W Michigan St, Indianapolis, 46202. to determine the antimicrobial effects of chlor-
presence of a periapical radiolucent
hexidine gluconate when used as irrigant in the
endodontic treatment of teeth with necrotic
pulps. J Endod 8:200-204, 1982.

375