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Endodontic Topics 2002, 3, 41–51 Copyright C Blackwell Munksgaard Printed in Denmark. All rights reserved ENDODONTIC TOPICS 2002
Consideration of steroids for
endodontic pain
J. GORDON MARSHALL
Up to 80% of endodontic patients who report with preoperative pain continue to experience some level of painfollowing the endodontic procedure. Since endodontic pain is often associated with chronic inflammation, thepresence of bacterial by-products, influx of primed immune cells and activation of the cytokine network andother inflammatory mediators, pain may be reduced by administration of glucocorticoid steroids. This reviewwill include the pharmacology, pharmacodynamics and purported mechanisms of actions of steroids as well astheir indications for endodontics, contraindications, dosages and side-effects.
Endodontic post-treatment pain continues to be a cacy of a wide variety of analgesics for their ability to significant problem facing the dental profession (1, ameliorate dental pain (8, 9, 11, 16–18). Most of 2). For those patients presenting with preoperative these studies have used an oral surgical third molar pain, it has been reported that up to 80% of this extraction model that evaluated pain of an acute in- population will continue to report pain after endo- flammatory nature. In contrast, endodontic pain is dontic treatment, with pain levels ranging from mild often associated with chronic inflammation, the pres- to severe (3–5). Many studies (3–13) have demon- ence of bacterial by-products, influx of primed im- strated that endodontic treatment either in the form mune cells and activation of the cytokine network and of pulpotomy or pulpectomy is efficacious in reducingpost-treatment pain (for details, see article by P. Ro-senberg in this issue of Endodontic Topics). As can beseen (Fig. 1) the pain relief afforded by endodontictreatment is effective but rarely immediate and com-plete. Post-treatment pain is usually mild in naturerarely lasts longer than 72 h and is usually well man-aged with non-steroidal anti-inflammatory agents(NSAID) or acetaminophen.
However, some patients will continue to have pain at moderate to severe levels that persists for severaldays even after appropriate endodontic treatment.
For example, in patients who present for treatmentwith a diagnosis of a symptomatic necrotic tooth, 47–60% may expect moderate to severe pain in the first24 h post treatment and 16–24% of patients at 72 h Fig. 1. Effect of pulpotomy on pulpectomy procedures on
postoperatively (14, 15). From these studies, it is reducing post-treatment endodontic pain (100% Ω pre-oper-
ative level of pain). From: Hargreaves KM & Baumgartner
evident that post-treatment analgesic intervention is JC. Endodontic Therapeutics. In: Walton R, Torabinejad
required in a variable percentage of endodontic cases.
M, eds. Principles and practice of endodontics. Philadelphia:
Numerous clinical studies have evaluated the effi- WB Saunders, pp 530–544, 2002 (20).
other inflammatory mediators (19). The chronicity of albumin and corticosteroid-binding globulin (CBG pulpal and periapical inflammation may permit or transcortin), account for most of these steroid sprouting of nociceptor terminals and thus change binding sites. Only the unbound portion of cortico- the peripheral anatomy of the pain system (21). It is steroid is free to enter cells and mediate effects; thus, possible that the efficacy of analgesics differs when 90% of total plasma concentration of steroids is not comparing the pain associated with acute postopera- pharmacologically active. Cortisol has a biologic half- tive inflammation due to oral surgery, with pain as- sociated with the more persistent inflammatory pro- Chemical modifications of the cortisol molecule cess observed in endodontic pain patients.
have produced a number of synthetic glucocorticoids Various classes of drugs have been studied for the with greater biologic half-lives, greater anti-inflamma- management of post-treatment endodontic pain (3, tory properties and less mineral corticoid activity 4, 9, 11, 13, 14). These include non-narcotic anal- (Table 1). The adrenal cortex produces approximately gesics comprising NSAID’s and acetaminophen, 10 mg/day of cortisol in the non-stressed adult (22).
opioids and steroids. The purpose of this article is to Under severe stress, this level may be increased more consider the use of steroids specifically glucocortico- than 10 fold. The metabolism of steroids takes place ids in the management of endodontic pain. This re- in hepatic and extrahepatic sites and involves sequen- view will focus on the pharmacology, purported tial additions of oxygen or hydrogen molecules fol- mechanisms of actions of steroids, as well as their in- lowed by conjugation to form water-soluble deriva- dications for endodontics, contraindications, dosages tives that are excreted in urine. Little biliary or fecal and side-effects. The history of steroid use in endo- excretion of steroids is seen in human beings.
dontics will be covered as well as a critical evaluation Glucocorticoids inhibit the production by multiple of the research done to date on the effects of gluco- cells or factors that are important in producing the corticoids on endodontic post-treatment pain.
inflammatory response. This inhibition is a result of The adrenal cortex synthesizes fat-soluble cortico- the effect of glucocorticoids on gene transcription steroids from cholesterol. These steroids contain 21 that produces a decrease in the release of vasoactive carbon atoms in a four membered hydrocarbon ring and chemoattractive factors, decreased secretion of system. Corticosteroids comprise glucocorticoids and lipolytic and proteolytic enzymes, decreased extrava- mineral corticoids. This review focuses on the gluco- sation of leukocytes to areas of tissue injury, and ulti- corticoids since they act at multiple sites to inhibit im- mately decreased fibrosis (22). Glucocorticoids also mune and inflammatory reactions. In humans, cortisol produce profound effects on the immune response by is the primary glucocorticoid that is continuously syn- inhibition of cytokine production, specifically inter- thesized and secreted from the adrenal cortex. This feron g, granulocyte/monocyte colony stimulating process is under the control of the hypothalamus and factor (GM-CSF), interleukins 1, 2, 3, 6 (IL-1, IL-2, anterior pituitary. Along with the adrenal cortex, they IL-3, IL-6) and tumor necrosis factor a (TNF a) make up the hypothalamic-pituitary-adrenal (HPA) (Table 2). Thus, the pharmacological effects of gluco- axis, a system that regulates glucocorticoid levels (22).
corticoids oppose many of the inflammatory pro- The hypothalamus produces corticotropin-releasing cesses that are known to occur during periapical in- hormone (CRH), which travels to the anterior pitu- flammation. Indeed, the ability of glucocorticoids to itary via the hypothalamic-hypohyseal portal system decrease periapical inflammation after endodontic and stimulates the release of adrenocorticotrophic hor- treatment has been demonstrated in a dog model by mone (ACTH) by pituitary corticotropes. ACTH, a both Holland (23), and Smith et al. (24). Glucocort- peptide of 39 amino acids, is the main regulator of cor- icoids bind non-covalently with specific receptor pro- tisol secretion. In turn, glucocorticoids inhibit ACTH teins in target tissues to regulate the expression of secretion via direct and indirect actions inhibiting corticosteroid–responsive genes. These receptors (CRH) neurons resulting in decreased CRH release, have high specificity and affinity for natural or syn- and via direct effects on corticotropes.
thetic glucocorticoids. Once formed, the cytoplasmic Cortisol and synthetic glucocorticoids circulate in hormone-receptor complex becomes activated and the blood with 90% or more reversibly bound to enters the cell nucleus where it directs the transcrip- plasma proteins. Two circulating plasma proteins.
tion of specific mRNA. The newly formed mRNA is processed within the nucleus and then translocates to served in the saline group at 1 day, but this difference the ribosomes to serve as a template for newly syn- was not statistically significant. Thus, steroid treat- thesized proteins that are responsible for the biologic ment to endodontic patients results in significant re- effects (25). Examples of steroid-induced protein syn- ductions in pulpal concentrations of PGE2, with a thesis include lipocortin 1, a 37-kDa protein that has trend towards a reduction in cytokine levels.
antiphospholipase A2 activity (26). Lipocortins pre- Glucocorticoids also induce synthesis of kinase II vent the synthesis of arachadonic acid and thereby re- or angiotensin converting enzyme (ACE), which can duce the biosynthesis of both cyclo-oxygenase and lead to a reduction of bradykinin. Bradykinin has four leukotrienes and thromboxane related substances dilation, increased vascular permeability, leukocyte (25). From this perspective, lipocortins represent one chemoattraction, and nociceptor activation (28).
of the body’s natural ‘NSAID-like’ proteins. Gluco- Bradykinin activates sensory nociceptors and elicits corticoids also inhibit the induction of the gene cod- release of substance P, neurokinin A, and calcitonin gene-related peptide (CGRP) via receptors B1 and Reductions in pulpal levels of both PGE2 and IL-8 B2. The pain of acute inflammation appears to be me- in cases of untreated irreversible pulpitis have been diated by B2 receptors, whereas the pain of chronic demonstrated after the administration of the gluco- inflammation appears to involve an increased number corticoid Depo-Medrol (27). Forty patients with a di- of B1 receptors (29). Reduction of bradykinin levels agnosis of irreversible pulpitis randomly received, in a and postoperative pain by the administration of gluc- double blind fashion, an intraosseous injection (IO) ocorticoids has been demonstrated by Hargreaves & of either 40 mg of methylprednisolone or sterile sa- Costello (30) using microdialysis probes in the oral line. No endodontic treatment was performed, the teeth were extracted at either 1 or 3 days after IO in- Glucocorticoids have also been shown to produce jection and pulp tissue was removed. Enzyme a protein termed ‘vasocortin’, which has the ability to immunoassay of the pulp tissue demonstrated a sig- suppress edema that is not suppressed by NSAIDs nificantly lower concentration of PGE2 at 1 day post (22). Nitric oxide synthase is inducible by pro-inflam- steroid injection. Mean pulpal concentrations of IL-8 matory cytokines resulting in increased nitric oxide in the steroid group were only 17% that of levels ob- production. Nitric oxide may increase blood flow and Table 1. Pharmacokinetics and relative potencies of corticosteroids
* Dosages are approximate and apply to oral or intravenous administration, as glucocorticoid potencies may vary greatly following intramuscular administration.
** This agent is not used for glucocorticoid effects.
Table 2. Effects of glucocorticoids on components of inflammatory/immune responses (adapted from Schimmer
and Parker (22), and Barnes (26))
Glucocorticoid effect ongene transcription Inhibition via glucocorticoid induction of lipocortin that inhibits phospholipase A2(macrophages, monocytes, fibroblasts) Anti-inflammatory cytokine secreted by macrophagesinhibits transcription of many pro-inflammatorycytokines, chemokines and inflammatory enzymes Cytokines exert multiple pro-inflammatory effects production and release blocked by glucocorticoids (macrophages, monocytes, lymphocytes, endothelialcells) Cytokine that block the binding of IL-1 to itsreceptors, glucocorticoids increase synthesis Chemokines attract inflammatory cells to site of inflammation, synthesis inhibited by glucocorticoids Nitric Oxide synthase may increase blood flow and plasma exudation and amplify inflammatoryresponse, potently inhibited by glucocorticoids Glucocorticoids inhibit the induction of the genecoding for COX-2 in monocytes and macrophages inflammation by decreasing tachykinins which may of tachykininreceptors, increasedexpression of neutralendopeptidase whichdegrades tachykinins Glucocorticoids suppress bradykinin levels by increased degradation of bradykinin via induction vasodilation, increased vascular permeability,nociceptor activation, and leukocyte attraction plasma exudation, thus amplifying the inflammatory cyclo-oxygenase, which converts arachadonic acid to response. Glucocorticoids produce a potent inhi- prostaglandin endoperoxides. Glucocorticoids could bition of nitric oxide synthase, leading to a decrease in therefore be presumed to have greater anti-inflamma- inflammation (26). Glucocorticoids may also inhibit tory and possibly greater analgesic properties than the neurogenic inflammation by inhibition of the release NSAIDs in pain conditions where multiple inflamma- tory mediators are present and contribute to the de- In contrast to the multiple sites of action and multiple anti-inflammatory effects of glucocorticoids, Several studies have reported that glucocorticoids the anti-inflammatory and analgesic effects of suppress postoperative edema in oral surgery patients NSAID’s are much more selective. NSAIDs are be- (18, 31–33). It may be conjectured that in an endo- lieved to act primarily via inhibition of the enzyme dontic pain model a reduction in periapical edema in a relatively non-compliant area might lead to a reduc- therefore prevents manifestations of adrenal insuf- ficiency. NSAIDs should not be used with steroids Most of the effects mediated by glucocorticoids are due to increased GI adverse effects.
not immediate since time is required for changes in The anti-inflammatory properties of glucocortico- gene expression and protein synthesis to occur; thus, ids were first appreciated and utilized as an adjunct to steroid actions many only be apparent after several endodontic therapy almost half a century ago (39– hours or even days after administration. This delayed 41). Glucocorticoids have been used as a pulp-cap- onset of action has been shown in a study by Nobu- ping agent (42), as an intracanal medicament either hara et al. (34), where administration of systemic alone or in combination with antibiotics/antihistam- dexamethasone significantly reduced the numbers of ines (13, 39, 40, 43, 44), and systemically (3, 4, 9, PMN’s in periapical tissue after endodontic over-in- 14, 41, 45–50) as a means to decrease pain and in- strumentation but not until 48 h postoperatively.
flammation in endodontic patients. The following Glucocorticoids have been used in endodontics for section will critically evaluate this research and then their potent anti-inflammatory effects. They may have make recommendations for the use of glucocorticoids widespread effects on many organ systems but these in endodontics; these recommendations will include, effects are typically only seen at supraphysiological indications, contraindications, case selection, agent, doses given over a long-term period, usually more dosage, and route of administration.
than 2 weeks. It has been stated that ‘A single dose of Several studies have evaluated the intracanal admin- glucocorticoid, even a large one, is virtually without istration of steroids in endodontic patients. Wolfsohn harmful effects, and a short course of therapy up to (39) in 1954 first reported on the use of a steroid 1 week) in the absence of specific contraindications, is as an intracanal medicament. His uncontrolled report unlikely to be harmful’ (22). This has been demon- included 79 cases of either acute serous or acute sup- strated in an in vivo study by Czerwinski et al. (35) parative pulpitis. After instrumentation, 0.5 mL of who concluded that single large doses (2 mg/kg) of hydrocortisone was placed into the canal(s) followed dexamethasone were essentially without harmful side- by a temporary filling. Patients reported their pain at effects. This dosage is 10–25 times the amount advo- 24, 48 and 72 h. The author concluded that the use cated for endodontic pain attenuation.
of hydrocortisone resulted in the reduction and elim- Glucocorticoids are contraindicated in patients with ination of severe secondary inflammatory reactions in systemic fungal infection and known hypersensitivity the periodontal membrane following treatment.
to the drug. Steroids should be used with caution in Blitzer (40) recommended the use of TACT (terra- patients with ulcerative colitis, pyogenic infection, di- mycin, antihistamine, cortril (25 mg/cc hydrocorti- verticulitis, peptic ulcer, renal insufficiency, hyperten- sone) and tetracyn) as an intracanal medicament in sion, osteoporosis, pregnancy, diabetes mellitus, ocu- cases where polyantibiotic therapy had failed. He re- lar herpes, acute psychosis and history of tuberculosis ported on 51 cases, of which only two were failures, (36). Psychological disturbances can occur during and concluded that hydrocortisone aids materially in glucocorticoid therapy. These reactions are reversible reducing inflammation in the periapical tissues.
and range in severity from mild (euphoria, insomnia, Ehrmann (43) reported on the use of Ledermix or nervousness) to pronounced (manic-depressive or (triamcinolone and dimethylchlorotetracycline in a schizophrenic psychosis). The frequency and severity water soluble cream) for pulp capping, exposures, and of adverse effects are correlated to the dose and dur- as an intracanal medicament in cases with pericemen- ation of therapy (37). Drug interactions associated titis. He concluded that Ledermix stopped the pain with the corticosteroids appear to be minimal. Cer- associated with pericementitis. Langeland et al. (44) tain drugs decrease blood levels of the steroid via in- used Ledermix as an intracanal medicament in cases creased metabolic clearance; these include phenobar- of continued postoperative pain after pulpal extir- bital, phenytoin, rifampin, and ephedrine. Short-term pation or canal instrumentation. They reported pain steroid use can produce a reversible suppression of relief in these cases within minutes to a few hours endogenous cortisol production. Williamson et al.
after the placement of Ledermix. In a double-blind (38) have shown that this suppression is compensated clinical study of 50 consecutive patients with vital for by adequate amounts of synthetic steroid and pulps, another study compared the use of 0.1 cc/ca- nal of dexamethasone (4 mg/cc) to sterile saline 0.1 patients with interappointment pain were included in cc/canal as an intracanal analgesic (51). After com- this study. Previously instrumented teeth were re- plete instrumentation, the intracanal medicament was opened without anesthesia, and medicated with either placed in the canal(s) followed by a temporary filling.
Patients recorded their preoperative pain levels as well 2.5 mg/g, gramicidin 0.25 mg/g, triamcinolone 1.0 as post treatment pain at 24, 48 and 72 h. The mg/g in aqueous cream base) or placebo (aqueous authors reported that the dexamethasone group had cream) and coronally sealed with Cavit. Patients re- significantly less pain at 24 h when compared to pla- corded pain as none, mild, moderate and severe at 1, 2, cebo (P Ͻ 0.05). No postoperative infections were 4, 8, 12, and 24 h post medication. Results showed that the intracanal use of corticosteroid-antibiotic medi- Chance et al. (52) in a double-blind study com- cation significantly reduced the mean pain score at all pared the effect of intracanal meticortelone (pred- time periods when compared to placebo (P Ͻ 0.001).
nisolone acetate 2.5%) vs. saline on post treatment Several other studies have evaluated the effects of pain in 280 patients. The preoperative pulpal and systemically administered steroids for treating endo- periapical diagnosis was recorded for each patient; dontic pain patients. The systemic administration of a however, pretreatment pain levels were not noted.
corticosteroid to alleviate pain and inflammation in After complete instrumentation, the intracanal solu- endodontic patients was first reported by Stewart & tion was placed in the canal via three applications of Chilton (41) in 1958. The authors reported on 107 a saturated paper point followed by a cotton pellet patients who presented for endodontic treatment and temporary filling. Patients reported their pain at with severe infection and swelling or had a postopera- 24 h post treatment. The results indicate that the tive ‘flare-up’ (see article by R. Walton in this issue of corticosteroid was effective in significantly reducing Endodontic Topics for more information on flare-ups).
the incidence of pain in vital teeth when compared After canal instrumentation and temporization, the to saline (P Ͻ 0.05). There was no difference in pain patients received a combination of corticosteroid, an- incidence in necrotic teeth when comparing the two tihistamine, and antibiotic to be taken orally. This combination included metreton (2.5 mg prednisone, Rogers et al. (13) compared the pain-reducing effi- 2 mg chlorophenpyridamine) 1 tablet TID for 2 days cacy of dexamethasone and ketorolac when used as and penicillin 250 mg TID for 3 days. Conclusions an intracanal medication, with oral ibuprofen and a were that the use of corticosteroid-antihistamine-anti- placebo. Forty-eight patients were included in the biotic therapy before or after conservative endodontic study. Following instrumentation of the vital pulps, therapy appeared to be very helpful in reducing acute two groups received either 0.1 mL dexamethasone (4 mg/mL) or 0.1 mL ketoralac tromethamine (30 Stewart (54) evaluated the effect of oral dexametha- mg/mL) as an intracanal medicament. The other two sone either alone or in combination with oral penicil- groups received no intracanal medication and either lin on endodontic post treatment inflammation.
ibuprofen (600 mg) or an oral placebo. Patients re- Teeth with vital or necrotic pulps were included. After corded their pain pretreatment and post treatment at endodontic instrumentation and temporization, pa- 6, 12, 24 and 48 h after therapy initiation on a visual tients were divided into four groups; a control group analog scale. At the 12-h period, both dexamethasone that received no medication, an antibiotic group that and ketoralac provided statistically better pain relief received phenethicillin 250 mg TID for 3 days, a ster- than placebo (P Ͻ 0.05). At the 24-h period, only ke- oid group that received dexamethasone 0.75 mg BID toralac had better pain relief than placebo. There for 2 days, and an antibiotic/steroid group that re- were no differences at 6 and 48 h. No differences ceived both phenethicillin and dexamethasone. In his were seen between groups in the amount of post- summary, the author stated that ‘dexamethasone is capable of minimizing postoperative inflammation Negm (53) in a randomized, double-blind study and consequent edema and pain thus substantially re- determined the effect of a corticosteroid-antibiotic combination compared to placebo for the treatment In a randomized, prospective, double-blind, pla- of post treatment pain in vital teeth. A total of 480 cebo controlled study by Marshall & Walton (3), the effect of intramuscular injection of dexamethasone on effect of four different doses of dexamethasone on post treatment endodontic pain was compared to pla- post treatment endodontic pain. All 106 patients in- cebo. After endodontic instrumentation and/or ob- cluded in the study presented with pretreatment pain.
turation, patients received an IM injection of 1.0 mL Endodontic instrumentation and/or obturation were of dexamethasone (4 mg/mL) or 1.0 mL of sterile sa- performed after which patients received a randomized line. Pain levels were recorded preoperatively and at intraoral intramuscular injection of placebo (1 mL 4, 24 and 48 h post treatment. Results indicated that sterile saline), or one of four doses of dexamethasone dexamethasone significantly reduced pain incidence (2 mg/mL, 4 mg/mL, 6 mg/mL, 8 mg/mL). The in- and severity at 4 h post treatment. At 24 h post treat- jection was given into either the masseter, internal ment, patients who received the corticosteroid ptyergoid, or buccinator muscle. Preference was given showed a trend towards less pain. Teeth with vital and to intraoral muscles anesthetized for treatment. Pa- necrotic pulps were included as well as retreatment tients recorded their pretreatment pain levels on a 0– cases. No antibiotics were taken by any patients and 9 scale and post treatment pain levels at 4, 8, 24, 48 there were no post treatment infections reported. The and 72 h. Type and amounts of pain medication taken amount of postoperative pain medication required was also recorded. No antibiotics were given at any time during this study and both vital and necrotic Krasner & Jackson (45), in a double-blind study, teeth were included for treatment. Results showed evaluated the effect of oral dexamethasone on post patients receiving dexamethasone had significantly treatment endodontic pain. Fifty patients presenting less severe pain at 4 and 8 h postoperatively (P Ͻ for endodontic treatment were included in this study.
0.05), and took significantly less pain medication Retreatment cases and patients presenting with puru- (P Ͻ 0.05) compared to placebo (mean of 1.98 tablets lent drainage or cellulitis were excluded. Teeth were for dexamethasone vs. mean of 4.64 tablets for pla- instrumented and closed with no intracanal medic- cebo). When evaluated on a mg/kg dosage basis, it ament. Pre-treatment and 8 and 24 h post treatment was found that patients who received 0.07–0.09 mg/ pain levels were recorded on a 0 to 100 scale. Patients kg of dexamethasone IM had significantly less pain at randomly received dexamethasone (0.75 mg/tablet) 8 h and took significantly fewer pain medications or placebo with instructions to take 3 tablets immedi- ately and then 1 tablet every 3 h until bedtime for a Kaufman et al. (47) were the first to evaluate the ef- total of 7 tablets. Results showed that patients re- fect of an intraligamentary delivery of corticosteroid ceiving oral dexamethasone had significantly less pain on endodontic post treatment pain. Forty-five patients at 8 and 24 h when compared to those receiving pla- presenting for endodontic treatment were randomLy assigned to one of three experimental groups. Endo- Glassman et al. (46) also evaluated the efficacy of dontic treatment was completed in one appointment oral dexamethasone on endodontic interappointment on both vital and necrotic pulps, with and without peri- pain but with a much higher dosage of the cortico- apical radiolucencies. After anesthesia was achieved but steroid. Forty patients with asymptomatic vital in- prior to endodontic treatment, patients in group 1 re- flamed pulps were included in this study. After endo- ceived 4–8 mg of Depo-medrol (slow-release methyl- dontic instrumentation and temporization, alternate prednisolone) via intraligamentary syringe. Single- patients were given either dexamethasone(4 mg/tab- rooted teeth received 4 mg, and multirooted teeth 8 let) or placebo. Instructions were to take 1 tablet im- mg. Group 2 received PDL injection of mepivacaine mediately and then 1 tablet at 4 and then 8 h post 3% in a similar fashion to group 1. Group 3 received no treatment for a total oral dose of 12 mg in the dexa- PDL injection. Pretreatment pain levels were not re- methasone group. Patients were given a questionnaire ported. The patients were telephoned at 24 h and re- to record pain on a visual analog pain scale at 8, 24, ported pain intensity on a 1–10 scale. The results and 48 h post treatment. Results showed that patients showed a significant decrease in postoperative pain in receiving dexamethasone had a statistically significant the methylprednisolone group (P Ͻ 0.05) compared to reduction in pain at all post treatment time periods.
the active and passive placebo groups. In another pros- Liesinger et al. (4) in a double-blind, randomized, pective, randomized, double-blind, placebo controlled prospective, placebo controlled study evaluated the study that contained 588 consecutive patients.
Torabinejad et al. (9), evaluated the effectiveness of endodontic treatment (complete debridement) pa- various medications on postoperative pain following tients in a double-blind fashion randomLy received complete instrumentation. The preoperative pulpal an intraosseous injection of either 1 mL methyl- and periapical diagnosis was recorded as well as pre- prednisolone (Depo-Medrol 40 mg/mL) or 1 mL of operative pain levels on a 0–9 scale. After instrumen- sterile saline placebo. All subjects received ibuprofen tation, patients were given one of 10 different medi- and Tylenol .3 and recorded their pain levels and cations or combination of medications. These in- any pain medications taken for 7 days postoperatively.
cluded non-steroidal anti-inflammatories, antibiotics, The results showed that the steroid group had signifi- acetaminophen, steroid and a narcotic analgesic. One cantly less postoperative pain and took significantly of these combinations was methylprednisolone 2 mg less pain medication over 7 days (P Ͻ 0.05). No anti- and penicillin 500 mg. Patients took one dose im- biotics were taken by patients at any time during the mediately then one dose every 6 h for the next 66 h for a total dose of 24 mg of methylprednisolone and In a follow-up study, Claffey et al. (49) evaluated 6 g of penicillin. Post treatment pain levels were re- pain reduction in symptomatic teeth with necrotic corded every 6 h for 72 h. Amongst their many find- pulps using an oral dose regimen of methylprednis- ings, the authors reported that those patients who olone. The materials and methods were nearly identi- presented for treatment with moderate–severe pain cal to Bramy et al. except that no patient had clinical and who received the steroid/antibiotic combination swelling and after the canal debridement, patients had significantly less pain at 6, 18 and 24 h when randomly received in a double-blind fashion either compared to the placebo group (P Ͻ 0.05). They oral methylprednisolone (48 mg/day for 3 days) or a found no significant post treatment pain differences placebo control (lactose 48 mg/day for 3 days). All between any of the test medications when compared patients received ibuprofen and Tylenol .3 (tm) and to placebo in patients with no or mild pretreatment a diary to record pain, percussion pain, swelling and number and type of pain medications taken. Clinical In a very elegant study, Gallatin et al. (48) evalu- success was defined as any patient who experienced ated pain reduction for untreated irreversible pulpitis only mild to no pain, mild to no percussion pain, mild using an intraosseous injection of methylprednis- to no swelling and did not take any Tylenol .3.
olone. Forty patients with a clinical diagnosis of irre- Again, no antibiotics were prescribed or taken during versible pulpitis actively associated with moderate–se- this study. The results showed that patients receiving vere pain participated in this prospective double-blind oral methylprednisolone had significantly higher clin- study. The involved tooth was anesthetized followed ical success for the first 3 days after endodontic treat- by an intraosseous injection of 1 mL methylprednis- olone (Depo-Medrol 40 mg/mL) or 1 mL of saline.
In critically evaluating the preceding studies for The blinded solutions were administered using the validity, it must be kept in mind that the most power- Stabident system (Fairfax Dental, Inc., Miami, FL, ful conclusions are those generated from studies that USA). No endodontic treatment was performed. Pa- are prospective, randomized, double-blind and pla- tients were given a 7-day pain diary as well as anal- cebo controlled. None of the endodontic reports on gesic medication. Over the 7-day observation period, the use of corticosteroids published prior to 1984 subjects receiving Depo-Medrol reported significant- meets these criteria and therefore the results should ly less pain (P Ͻ 0.05) compared to placebo while tak- be considered anecdotal. Results from studies that ing significantly fewer analgesic medications (P Ͻ used corticosteroids in combination with other agents such as an antibiotic and/or an antihistamine are dif- Bramy et al. (14) evaluated the intraosseous admin- ficult to interpret, as results ascribed to one of the istration of corticosteroid for pain reduction of symp- agents may be the result of the combination. Equally tomatic teeth necrotic teeth. Thirty-eight patients difficult to interpret are results from studies using in- with a clinical diagnosis of pulpal necrosis with associ- tracanal steroid as the means of delivery (13, 52, 53).
ated periapical radiolucency participated in the study.
The methodology in these studies doesn’t account for All patients experienced moderate/severe pain at time how much and over what time period the intracanal of presentation with mild or no clinical swelling. After medicament reaches the site of action, the periapical tissues. Very small concentrations of the agent are ministration. This is probably not the case, as seen placed into the canal(s) and assuming apical patency in Table 1 dexamethasone is approximately 5 times as of variable size must pass through the apical foramen potent as methylprednisolone and the 6–8 mg intra- via a concentration gradient against a potential back muscular doses used by Liesinger et al. (4) would be pressure from periapical transudate or exudate. This equivalent to 30–40 mg of methylprednisolone with would seem to leave those studies that administered 40 mg of intraosseous methylprednisolone being the corticosteroids in a systemic manner (intramuscular, dose used by Bramy et al. (14). It is possible to specu- intraosseous, oral) in a known dose without any other late that these differences therefore might be more agents as the critical ones in evaluating the efficacy of related to the preoperative pulpal and periapical diag- steroids in the ability to decrease endodontic pain.
nosis. All of the patients in the studies by Bramy et al.
Prior to interpreting these studies (3, 4, 13, 45–49) it and Claffey et al. (14, 49) presented with necrotic is important to remember that endodontic treatment pulps, associated periapical radiolucencies, and either itself has a major effect on reducing post treatment mild or no swelling. The majority of patients in the pain regardless of analgesic intervention (Fig. 1). As study by Liesinger et al. (4) presented with a diag- stated by Hargreaves (19) ‘This reduction in post nosis of irreversible pulpitis and acute apical peri- treatment pain, combined with variable levels of pre- odontitis and those patients with necrotic pulps had operative pain, reduces the statistical power of endo- no associated periapical radiolucencies. It seems dontic clinical trials for detecting active analgesics plausible that corticosteroids may be more efficacious over time in all patient groups (the so-called floor ef- in attenuating pain associated with pulpal necrosis fect). This limitation is a problem in interpreting clin- and associated radiolucencies compared to pain as- ical studies in general and may explain why some en- sociated with irreversible pulpitis since these con- dodontic clinical trials fail to detect analgesic treat- ditions are associated with more complex chronic in- ment or only detect it in those patients with flammatory processes. Thus, the efficacy of steroids moderate/severe pain.’ This has been shown by Tora- in endodontic pain patients could be related to vari- binejad et al. (9) and Rogers et al. (13) where various ations in the periapical immunological/inflammatory agents including corticosteroid significantly decreased dynamics of teeth with irreversibly inflamed vs. ne- post treatment pain but only in those patients who presented with at least moderate/severe pretreatment Based on the work of Bramy et al. and Claffey et al.
pain. It would therefore seem that systemic adminis- (14, 49), it also seems plausible that corticosteroids tration of corticosteroid as a method to decrease en- would have efficacy in those cases of endodontic flare- dodontic post treatment pain might be appropriate up that result after treatment of previously asympto- only for those patients who present with moderate/ matic necrotic teeth with or without associated peri- severe pain. Three independent studies (4, 14, 49) apical radiolucencies. This premise has not been in- meet the criteria of being prospective, randomized, vestigated and, with the low incidence of this type of double-blind placebo controlled with no drug combi- flare-up (1), would require a multicenter study over nations and including only patients who presented a period of years to gather an adequate sample size.
with the required level of pretreatment pain. Import- Collectively, it appears from the studies reported (4, antly, these studies showed that systemic administra- 14, 49) that the route of systemic administration of tion of corticosteroid not only significantly reduced glucocorticoids is not a determinant in their efficacy post treatment pain at various times but also signifi- and that when given in equivalent dosages, agents cantly reduced the amount of additional pain medi- such as dexamethasone and methylprednisolone are interchangeable. It would seem that if a systemic ster- Interestingly, the reports by Bramy et al. (14) and oid is to be administered, an intraoral IM injection or Claffey et al. (49) show significant pain relief for up an intraosseous injection would be preferable over an to 7 days with the use of steroid, in contrast to Lies- extraoral IM injection as the practitioner is familiar inger et al. (4) who found significant differences in with intraoral and intraosseous injections and the site pain reduction only in the first 8 h. It is possible these of injection is already anesthetized. Intraoral injection differences could be due to differences in doses of of steroid would be preferable to a prescription for different corticosteroids or by different routes of ad- glucocorticoid as no assumption about patient com- pliance is required. A dose of 6–8 mg of dexametha- 4. Liesinger A, Marshall FJ, Marshall JG. Effect of variable doses of dexamethasone on post treatment endodontic sone or 40 mg of methylprednisolone appears from pain. J Endod 1993: 19: 35–39.
the literature to be appropriate. If an oral route is 5. Marshall JG, Liesinger AW. Factors associated with endo- chosen 48 mg methylprednisolone/day for 3 days and dontic post treatment pain. J Endod 1993: 19: 573–575.
by extrapolation 10–12 mg dexamethasone/day for 3 6. Hasselgren G, Reit C. Emergency pulpotomy. Pain reliev- ing effect with and without the use of sedative dressings.
days should provide significant post treatment pain J Endod 1989: 15: 254–256.
7. Oguntebi BR, DeShepper EJ, Taylor TS, White CL, Pink It has been stated (38, 41, 50, 55) that antibiotics FE. Postoperative pain incidence related to the type of must be given in conjunction with steroids to prevent emergency treatment of symptomatic pulpitis. Oral Surg an infection secondary to a decrease in the inflamma- Oral Med Oral Pathol 1992: 73: 479–483.
8. Penniston SG, Hargreaves KM. Evaluation of periapical in- tory response. The implication is that suppression of jection of Ketorolac for management of endodontic pain.
inflammation also means a decrease in local defenses J Endod 1996: 22: 55–59.
permitting unchecked proliferation of pathogenic 9. Torabinejad M, Cymerman JJ, Frankson M, Lemon RR, microorganisms. None of the studies published since Maggio JD, Schilder H. Effectiveness of various medi-cations on postoperative pain following complete instru- 1984 would support this premise, including those mentation. J Endod 1994: 20: 345–354.
cases with a diagnosis of pulpal necrosis with peri- 10. Moos HL, Bramwell JD, Roahen JO. A comparison of pul- apical radiolucency (14, 49) where the potential for pectomy alone versus pulpectomy with trephination for the dissemination of an infectious process might be ex- relief of pain. J Endod 1996: 22: 422–425.
11. Doroshak A, Bowles W, Hargreaves K. Evaluation of the pected. Antibiotics were not given or needed at any combination of flurbiprofen and tramadol for management time during these studies nor were the steroids associ- of endodontic pain. J Endod 1999: 25: 381–384.
ated with any increase in infection rate compared to 12. Rosenberg PA, Babick PJ, Schertzer L, Leung A. The ef- the control group. It can therefore be concluded that fect of occlusal reduction on pain after endodontic instru-
mentation. J Endod 1998: 24: 492–496.
antibiotics are not routinely required or recom- 13. Rogers MJ, Johnson BR, Remeikis NA, BeGole EA. Com- mended in conjunction with corticosteroids for the parison of effect of intracanal use of ketorolac tromethami- management of endodontic post treatment pain in ne and dexamethasone with oral ibuprofen on post treat- the otherwise healthy patient. Several excellent re- ment endodontic pain. J Endod 1999: 25: 381–384.
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