Aust Endod J 2019

LITERATURE REVIEW

Effect of occlusal reduction on postendodontic pain: A systematic

review and meta-analysis of randomised clinical trials
David Nguyen, BDS, BPharm1; Venkateshbabu Nagendrababu, BDS, MFDS RCPS (Glasgow), MDS, PhD2 ;
Shaju J. Pulikkotil, BDS, MDS, PhD2; and Giampiero Rossi-Fedele, DDS, MClinDent, PhD3
1
Melbourne Dental School, University of Melbourne, Melbourne, Victoria, Australia
2
Division of Clinical Dentistry, School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
3
Adelaide Dental School, University of Adelaide, Adelaide, South Australia, Australia

Keywords
apical periodontitis, endodontics, meta-
analysis, pain, root canal, systematic review.
Correspondence
Professor Giampiero Rossi-Fedele, Adelaide
Dental School, North Terrace C/O George
Street, Adelaide, SA 5005, Australia. Email:
giampiero.rossi-fedele@adelaide.edu.au
doi: 10.1111/aej.12380
(Accepted for publication 22 September 2019.)
Abstract
The purpose of this systematic review was to assess the effect of occlusal reduc-
tion on post-operative pain following root canal treatment and was performed
in accordance with the PRISMA statement being registered in the PROSPERO
database (CRD42018089941). Two reviewers independently conducted a sys-
tematic literature search in the PubMed (MEDLINE), Dentistry & Oral Sciences
Source and the Cochrane Library databases. Seven studies were included, of
which three were used to perform meta-analysis for 6 days post-operative and
the rest for qualitative synthesis. Three studies were assessed as low risk of bias,
three as some concern, and one as high risk of bias. Occlusal reduction dimin-
ishes the post-operative pain (SMD 1.10 (95%CI 2.06, 0.15) I2 = 96.9%)
at 6 days for teeth diagnosed as irreversible pulpitis, and, overall, likely reduces
post-operative pain for patients presenting with irreversible pulpitis and/or
symptomatic apical periodontitis. Future high-quality clinical trials are needed
to better understand the role of occlusal reduction.

administration of preoperative medication (7), use of

Introduction
Pain subsequent to root canal treatment (RCT) presents
as an important concern for both clinicians and patients.
Indeed, patients may even view the effective manage-
ment of post-operative pain as a measure of the clini-
cian’s abilities and knowledge (1). The prevalence of
post-operative pain after RCT has been reported to be
3%–58% of cases (2). However, post-operative pain has
been shown to have a predictable course of progression,
with pain severity halving after the first day post-treat-
ment and decreasing to <10% after 7 days (3).
Post-operative pain during RCT is multifactorial (4).
Mechanical, chemical and microbial factors relating to
instrumentation may also contribute to the periapical
inflammatory processes, affecting the prevalence and
severity of post-operative pain (5). The perception of
post-operative pain also varies amongst patients as it is
highly subjective and may be influenced by social beha-
viours, cultural learning and psychological factors (6).
Several treatment modalities have been suggested to
reduce post-operative pain following RCT including
long-acting anaesthetics solutions (8), administration of
post-operative medication (9), use of 5.25% sodium
hypochlorite as main irrigant solution (10), machine-as-
sisted irrigant agitation (11), use and type of intra-canal
medicament (12–14), low-level laser therapy (15), glide
path preparation (16), rotary instrumentation (17,18)
and cold lateral compaction filling technique (19).
Occlusal reduction (OR) has long been practised as a
method of reducing post-operative pain during RCT. Pro-
ponents of OR theorise that removal of occlusal contacts
reduces mechanical stimulation of sensitised nociceptors
present in the periodontal ligament (20). In other words,
OR may decrease the pressure on a tooth with inflamed
periapical tissues, alleviating the effect of mechanical
allodynia. Potential benefits of OR on endodontic pain
have been assessed in the management of pulpal and
periapical conditions (21,22), as well as in the presence of
reported symptoms (23), radiographic findings and/or
clinical test(s) responses (23,24). However, the overall
results of the different clinical studies are inconsistent
and often conflicting.

© 2019 Australian Society of Endodontology Inc 1

Occlusal Reduction and Pain
There appears to be no consensus on the definition of
OR in the existing literature (21–24). Nevertheless, OR
generally involves the selective removal of dental hard
tissue substance with subsequent loss of some of the
anatomical features of the occlusal surface of the
involved tooth. This change of tooth form will alter habit-
ual intercuspation, modify perception and proprioception
and potentially alter existing occlusion schemes (25),
particularly in the absence of contralateral posterior
teeth, though the masticatory system is normally able to
balance such changes (26). Further eruption of teeth
may occur, affecting the relative alignment of the roots
and crown (27). However, the latter may not necessarily
occur, depending on systemic and local factors as well as
environmental influences (28). Similarly, OR in teeth
presenting with satisfactory extra-coronal restorations
need to be adequately justified.
To date, no systematic review and meta-analysis has
been published to find the influence of OR in managing
and/or preventing post-operative pain after RCT. There-
fore, the purpose of the present study is to critically anal-
yse clinical studies and ascertain the association between
OR and post-operative pain following root canal instru-
mentation. The clinical question was structured accord-
ing to Population, Intervention, Comparator, Outcome,
Study (PICOS) design: Did occlusal reduction (I) result in
less post-operative pain (O) compared to teeth without
occlusal reduction (C) in adults (P) following RCT proce-
dures in randomised clinical trials (S)?
Materials and methods
The current review was conducted and reported in strict
accordance with Preferred Reporting Items for Systematic
Reviews and Meta-Analysis guidelines (29). The protocol
of the present systematic review was registered at the
PROSPERO international prospective register of system-
atic reviews, and the registration number is:
CRD42018089941.
Eligibility criteria
Inclusion criteria:
1. Randomised clinical trials assessing the effect of OR on
post-operative pain in adult patients whilst performing
root canal treatment in teeth diagnosed with irreversible
pulpitis or apical periodontitis.
2. Post-operative pain measured by visual analogue scale
(VAS) after at least 6 h.
3. Full text published in English or Latin alphabet lan-
guages.
Exclusion criteria: case reports, case series, non-ran-
domised clinical trials or clinical technique reports or
2 © 2019 Australian Society of Endodontology Inc
D. Nguyen et al.
reviews were excluded as well as studies without quanti-
tative assessment of preoperative or post-operative pain.
Information sources and search strategy
Electronic searches were performed on PubMed (MED-
LINE), Dentistry & Oral Sciences Source (DOSS) and the
Cochrane Library databases including articles published
from inception through to 15 October 2018. The search
strategies are shown in Table S1. Reference sections of
the articles eligible for inclusion articles were also
searched for additional results using the same criteria.
Study selection process
After removal of duplicate publications, two investigators
(DN, GRF) screened the titles and abstracts of all articles
identified from the search. Articles that were not relevant
to the inclusion criteria were excluded. At the second
stage of the process, full-text evaluation of the remaining
articles was performed to determine their eligibility
against the inclusion criteria by the same authors. For
certain articles in which the abstract or title was not clear,
the full text was read to reduce the possibility of disre-
garding eligible studies. Any disagreement was resolved
by consensus.
Data collection process
For each article, the following general and clinical infor-
mation was independently extracted by the two investi-
gators (DN, GRF): author(s), year of publication, journal,
diagnosis and/or preoperative status, main inclusion and
exclusion criteria, sample size, treatment groups, intra-
operative treatment protocol, description of intervention
and control, assessment method, follow-up period and
conclusion. Any disagreement was resolved by consen-
sus.
Risk of bias assessment
The quality of the studies was evaluated by two indepen-
dent reviewers (GRF, VN) using the revised Cochrane
risk of bias tool for randomised trials (RoB 2.0) (30). Any
disagreement was resolved by a third reviewer (SP). The
tool was applied to assess five domains relevant to the
risk of bias: randomisation processes, deviations from
intended interventions, missing outcome data, measure-
ment of the outcome and selection of the reported result.
Based on predefined criteria, the studies were assessed as
‘low risk’, ‘some concerns’ or ‘high risk’ in all the
domains. An overall score on quality was then given for
each study based on the scoring of the domains. A study
D. Nguyen et al.
was judged to have an overall low risk of bias when all
the domains were scored as ‘low risk’. An overall score of
‘some concerns’ was given to any study when at least
one domain was scored as ‘some concerns’. Moreover, a
study was considered to have an overall high risk of bias
when at least one domain was scored as ‘high risk’ or
more than two domains were scored as ‘some concerns’.
Meta-analysis
Random-effects modelled meta-analysis (STATA 14.1
software; StataCorp, College Station, TX, USA) was used
to estimate the standardised mean difference (SMD)
between the groups (with or without occlusal reduction).
Heterogeneity was calculated by I2 statistic and was con-
sidered significant if was more than 50%. Publication bias
through funnel plot was assessed when sufficient studies
(more than 10) were available (31).
GRADE
The quality of evidence from meta-analysis was assessed
by the GRADE approach (GRADEpro GDT software
https://gradepro.org/) into very low, low, moderate or
high quality.
Results
Study selection
The results of the search process are presented in Figure 1.
References of the selected studies were manually
searched, with additional articles found. After removal of
duplicates, the search strategy yielded a total of 447 arti-
cles. After screening of titles and abstracts, 13 articles
were selected for full-text assessment. Six articles were
excluded at this stage (Table S2). Two articles were
excluded as their full texts were not available in English
or Latin alphabet languages (32,33). Furthermore, one
study was not a randomised clinical trial (24), two studies
did not assess pain using VAS (23,35) and another study
did not include OR (34). In total, seven studies
(21,22,36–40) were included in this systematic review.
Three studies were used to conduct meta-analysis to
assess the influence of OR on post-operative pain at day
six (36,37,39). Four studies were excluded from this
meta-analysis because pain was not measured on the 6th
day of follow-up (22,40) and/or no mean and SD were
presented for pain scores (21,38).
Study characteristics
The key features of each study are summarised in Table 1.
The studied population samples ranged from 35 to 402
patients. Only some studies described a rationale for their
© 2019 Australian Society of Endodontology Inc
Occlusal Reduction and Pain
sample sizes. Two studies (37,39) used a World Health
Organisation recommended sample size determination
software. Another three studies (21,22,40) reported
power values and sample size calculations; however, in
the Parirokh et al. study (21), the prescribed quota was
not reached due to drop-outs. The age range of partici-
pants was described in only some of the included studies
(36–38,40). All of the included studies allocated partici-
pants into two to three groups – one intervention group
representing participants who underwent occlusal reduc-
tion of the root canal-treated tooth and at least one con-
trol group in which no OR or limited OR of a non-
functional cusp was performed. Further detail of the
intervention (OR) is described in Table 1.
Disparities in the clinical protocols were noticeable across
the included studies. Irrigation with sodium hypochlorite
followed by dressing of the canal with calcium hydroxide
was described in five studies (21,36–39). However, in one
study, the root canal-treated teeth were temporised with
no intra-canal medicament present or its placement was
not explicitly reported (40). The concentration of sodium
hypochlorite as an irrigant solution also varied across the
included studies, ranging from 1.25% to 3%. Three of the
included studies used manual instrumentation (36,38,39)
and studies used rotary instrumentation (21,22,37,40).
Single-visit root canal treatments were also performed in
one study (22) using rotary files, EDTA and sodium
hypochlorite during canal preparation followed by
matched single cone and sealer for root canal filling.
Risk of bias assessment
The assessed quality of included studies is shown in
Table S3. Amongst the seven included studies, three
studies were judged to have overall ‘low’ risk of bias
(22,37,40). Three studies were deemed to have ‘some
concerns’ arising from bias due to randomisation process
(36,38,39). One study was judged to have an overall
‘high’ risk of bias as a result of the high risk of bias due to
missing outcome data (21).
Narrative synthesis
Results from the included studies were inconsistent, and
narrative synthesis was further complicated by the dis-
parities in the inclusion criteria for teeth/patients,
methodology, follow-up period and outcome assessment
(Table 1). Four of the studies found that OR did not have
a significant effect in reducing post-operative pain fol-
lowing RCT (21,22,36,38), whereas three studies deter-
mined that OR was effective in reducing or preventing
post-instrumentation pain (37,39,40). The latter were
associated with a priori sample size calculation with the
3
Occlusal Reduction and Pain D. Nguyen et al.

Identification
Records identified through database Additional records identified
searching through other sources
(n = 455) (n = 4)

Records after duplicates removed

(n = 447)
Screening

Records screened Records excluded

(n = 447) (n = 434)

Full-text articles excluded,

with reasons
Eligibility

Full-text articles assessed

for eligibility (n = 6)
(n = 13)
No English/Latin alphabet
language (n = 2)
Not randomised clinical
trial (n = 1)
No intra-operative occlusal
reduction (n = 1)
Studies included in Pain was not assessed
qualitative synthesis using VAS (n = 2)
(n = 7)
Included

Studies included in
quantitative synthesis
(n = 3)

Figure 1 PRISMA flow chart showing the results of the search process.

quota being reached (37,39,40). In general, narrative
synthesis suggests that OR was associated with reduced
post-operative pain in teeth diagnosed with irreversible
pulpitis which were distinctly tender to percussion. OR
also appeared to reduce post-operative pain in the pres-
ence of symptomatic apical periodontitis without remark-
able radiographic changes, although conflicting findings
were present. Finally, regarding pain reduction in the
first 24 h, one study reported significant differences for
the OR group only at 12 h (40), whilst the remainder
reported no significant differences (21,22,36,38).
day follow-up with a diagnosis of irreversible pulpitis
(SMD 1.10 (95%CI 2.06, 0.15) I2 = 96.9 %; Fig. 2).
Due to the limited number of studies (i.e. <10), publica-
tion bias through funnel plot was not carried out.
GRADE
Table S4 shows the GRADE evidence profile that substan-
tiated the evidence for effect of post-operative pain. The
GRADE evaluation showed that the evidence was of
‘very low’ quality.

Meta-analysis Discussion
Quantitative analysis from three studies (n = 762) OR is unlikely to reduce post-operative pain in teeth with
showed that the OR reduces post-operative pain at the 6- mild preoperative pain and/or mild tenderness to

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D. Nguyen et al. Occlusal Reduction and Pain

Table 1 Characteristics of included studies

Diagnosis and
preoperative status Chemo-mechanical
Authors, and/or main inclusion Groups, preparation and intra- Assessment method
year criteria n canal medicament Intervention/control and follow-up period Conclusion

Parirokh Symptomatic OR, 25 Working length OR: All occlusal VAS to evaluate OR in teeth with
et al. irreversible pulpitis NOR, 21 established with contacts on the preoperative pain irreversible pulpitis
2013 Response to an electronic apex functional and non- prior to local and mild tenderness
(21) electric pulp test locator confirmed functional cusps as anaesthesia to percussion had
and prolonged with periapical well as the marginal VAS completed at 6 h, no significant
moderate-to-severe radiograph ridges were reduced 12 h, 18 h, 24 h, influence on post-
pain to a cold test, Canals initially by 1 mm. 2 days, 3 days, operative pain after
mild tenderness to instrumented to file NOR: No reduction. 4 days, 5 days and root canal
percussion, normal size 15 and Occlusal reduction 6 days after preparation
periapical coronally prepared simulated with high- treatment to rate
radiographic with Gates-Glidden speed handpiece post-operative pain
appearance burs. HERO 642 activated inside (0, no pain; 1–3,
Posterior maxillary or rotary instruments patient’s mouth mild pain; 4–6,
mandibular teeth to prepare canal to without contacting moderate pain; 7–9,
with normal occlusal a size 30/0.4 file at tooth. severe pain)
contact against working length All patients instructed Additional VAS form to
opposing tooth/ Canals irrigated with to use analgesics evaluate effect of
teeth 1.3% sodium (600 mg ibuprofen analgesic
All patients reported hypochlorite and every 6 h) if medication if used
no to mild pain medicated with required for pain (0, no or mild pain
before starting calcium hydroxide relief that does not
treatment paste. Access cavity require analgesic
restored with medication; 1,
temporary moderate pain that
restorative material was well controlled
with analgesic
medication; 2,
unbearable pain
that was not
controlled with
analgesic
medication)

Asghar Irreversible pulpitis OR, 55 Working length was OR: All occlusal VAS to rate OR in teeth with
et al. Posterior tooth, mild NOR, established using an contacts on the preoperative pain irreversible pulpitis
2014 tenderness to 55 apex locator, and functional and non- prior to local and mild tenderness
(36) percussion, mild biomechanical functional cusps and anaesthesia to percussion had
preoperative pain, preparation was marginal ridges VAS completed upon no significant
normal periapical achieved using reduced by 1 mm. recall at 24 h, influence on canal
radiograph Gates-Glidden drills NOR: no occlusal 2 days and 3 days pain after root canal
appearance, and hand files reduction post-treatment to preparation
occlusal contacts Canals were irrigated rate post-operative
using 1.3% sodium pain (0, no pain; 1–
hypochlorite and 3, mild pain; 4–6,
dressed with moderate pain; 7–9,
calcium hydroxide severe pain)
paste and sealed
with a temporary
restorative material

(continued)

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Occlusal Reduction and Pain D. Nguyen et al.

Table 1 (continued)

Diagnosis and
preoperative status Chemo-mechanical
Authors, and/or main inclusion Groups, preparation and intra- Assessment method
year criteria n canal medicament Intervention/control and follow-up period Conclusion

Sheikh Irreversible pulpitis OR, 201 Working length OR: 1 mm of occlusal VAS to score post- OR aids in preventing
et al. Posterior teeth, NOR, established by reduction operative pain (0– post-
2015 opposing teeth, 201 electronic apex performed 10) at 6 h, 12 h, instrumentation
(37) sensitivity to locator and NOR: High-speed 18 h, 24 h, 2 days, pain in teeth with
percussion pre- confirmed with handpiece activated 3 days, 4 days, irreversible pulpitis,
treatment pain, measurements from inside patient’s 5 days and 6 days preoperative pain,
normal periapical a periapical mouth without after treatment pulp vitality,
radiograph radiograph contacting occlusal The final outcome was percussion
appearance Canals initially surface to simulate the mean post- sensitivity and the
negotiated by size procedure use in instrumentation absence of
15 K-files, followed intervention group pain score periradicular
by coronal measured at 6 days radiolucency
preparation with post-
Gates-Glidden burs, instrumentation
and canal
preparation finished
with ProTaper
rotary instruments
(size F1 or F2 to
working length)
3% sodium
hypochlorite used to
irrigate root canal
between
instrumentations
After canal
preparation, canals
medicated with
calcium hydroxide
and access cavity
sealed with
temporary
restorative material

(continued)

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D. Nguyen et al. Occlusal Reduction and Pain

Table 1 (continued)

Diagnosis and
preoperative status Chemo-mechanical
Authors, and/or main inclusion Groups, preparation and intra- Assessment method
year criteria n canal medicament Intervention/control and follow-up period Conclusion

Arslan Symptomatic apical OR, 13 Working length Preoperative data: VAS to score OR did not influence
et al. periodontitis Semi determined by using Following preoperative pain post-operative pain
2017 Severe tenderness to OR, electronic apex anaesthetisation, and pain level on in teeth diagnosed
(22) percussion, 11 locator teeth analysed for first, third, fifth and as symptomatic
preoperative VAS NOR, 11 Canal shaping and centric occlusion seventh day after apical periodontitis
more than 80, apical coronal flaring and percentage of the procedure
pathology on performed with S1, relative occlusal Post-operative
radiograph (<2 mm) S2, SX ProTaper force using a digital analgesic intake and
Maxillary and Universal rotary occlusal analysis initial/final
mandibular molar instruments. Apical system (T-Scan III) percussion pain (0,
teeth with presence preparation finished OR: Full reduction no pain; 1, slight
of opposing tooth/ with F1, F2, F3, F4 performed. pain; 2, severe pain)
teeth or F5 instruments. Selective grinding was also recorded
Additional 55–80 K- performed until
files used if needed. teeth had no
1.25% sodium occlusal contacts
hypochlorite used Semi OR: Post-
as irrigant between operative
each file percentage of
Final rinse performed relative occlusal
using 1.25% sodium force has become
hypochlorite and half of preoperative
17% EDTA value
Canal dried with paper NOR: Occlusal
points and reduction simulated
obturated with with high-speed
matched single cone handpiece activated
and AH Plus sealer. inside patient’s
Access cavity mouth without
restored with contact tooth.
composite resin Preoperative and
using incremental post-operative loads
technique were the same
All reduction process,
patients in all
groups instructed to
use 400 mg
ibuprofen if needed

(continued)

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Occlusal Reduction and Pain D. Nguyen et al.

Table 1 (continued)

Diagnosis and
preoperative status Chemo-mechanical
Authors, and/or main inclusion Groups, preparation and intra- Assessment method
year criteria n canal medicament Intervention/control and follow-up period Conclusion

Raza et al. Irreversible pulpitis OR, 50 Working length OR: occlusal contacts VAS to rate OR had no statistically
2016 History of moderate- NOR, 50 established with on cusps and preoperative pain significant effect on
(38) to-severe pain (VAS electronic apex marginal ridges prior to local post-operative pain
4–10), tenderness to locator and reduced by 1 mm anaesthesia relief after
percussion, normal confirmed with NOR: No occlusal VAS completed 24 h endodontic
periapical periapical reduction after instrumentation in
radiographic radiograph. instrumentation patients with
appearance, Canals initially procedure to rate irreversible pulpitis
posterior maxillary instrumented to file post-operative pain
and mandibular size 20, and as mild, moderate
teeth with normal coronally prepared or severe
occlusal contact with Gates-Glidden
against opposing burs.
tooth/teeth Canals irrigated with
1.3% sodium
hypochlorite, and
medicated with
calcium hydroxide
paste. Access cavity
sealed with
temporary
restorative material

Zaman & Acute irreversible OR, 125 Working length OR: All occlusal VAS to score OR reduces post-
Ahmed, pulpitis NOR, confirmed contacts on the preoperative pain instrumentation
2016 Prolonged pain to cold 125 radiographically functional and non- (0, no pain; 1–3, pain in patients
(39) and normal Canals prepared to functional cusps as mild pain; 4–6, undergoing
radiographic size 20-K file, well as the marginal moderate pain; 7–9, endodontic
appearance followed by coronal ridges were reduced severe pain) treatment of
Posterior maxillary preparation with by 1 mm VAS completed at posterior teeth
and mandibular Gates-Glidden burs NOR: No occlusal recall to rate pain at
teeth with normal 2.5% sodium reduction 24 h, 2 days,
occlusal contact hypochlorite used to performed 3 days, 4 days,
against opposing irrigate root canal 5 days and 6 days
tooth/teeth between post-operatively
instrumentations Final outcome was the
After canal mean post-
preparation, canals instrumentation
medicated with non- pain score
setting calcium measured at 6 days
hydroxide and
access cavity sealed
with temporary
restorative material

(continued)

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D. Nguyen et al. Occlusal Reduction and Pain

Table 1 (continued)

Diagnosis and
preoperative status Chemo-mechanical
Authors, and/or main inclusion Groups, preparation and intra- Assessment method
year criteria n canal medicament Intervention/control and follow-up period Conclusion

Emara Symptomatic OR, 22 Two visits (7 days OR: All occlusal VAS to score OR had a significant
et al. irreversible pulpitis NOR, 22 apart) contacts on the preoperative pain effect on the relief
2019 and symptomatic 1st visit: size 15 K-file functional and non- (0, none; 1–3, mild; of post-operative
(40) apical periodontitis introduced up to functional cusps and 4–6, moderate; 7– pain following root
Spontaneous apical foramen as the marginal ridges 10, severe) canal treatment in
moderate or severe indicated by were reduced – VAS completed at 6, teeth with
sharp throbbing electronic apex absence of contact 12, 24, 48 h symptomatic
pain related to a locator. Corrected confirmed with following the first irreversible pulpitis
posterior working length articulating paper visit then at 6 and and symptomatic
mandibular tooth confirmed NOR: highspeed 12 h following the apical periodontitis
Lingering pain radiographically. handpiece activated second visit only at 12 h post-
provoked by cold/ Canals mechanically above the tooth Incidence of placebo operatively after
hot stimulus and prepared with Revo- without contacting and analgesic intake chemo-mechanical
pain on biting/ S rotary nickel the occlusal surface at the end of each preparation and
chewing titanium files to size to simulate the visit (patients obturation
Positive response to 30, .06 taper; size procedure of the OR instructed to take
an electrical pulp 35, .06 taper; or size group placebo if
test 40, .06 taper. Canals experiencing
Tenderness to irrigated with 3 mL moderate or severe
percussion on of 2.5% sodium post-operative pain,
tapping the tooth hypochlorite and ibuprofen
No apical radiolucency following each file 400 mg in the case
or only slight Canals dried using of persistent pain)
widening of paper points, no
periodontal intra-canal
membrane space medicament used,
Posterior mandibular and cotton pellet
teeth with occlusal placed in pulp
contact chamber
Access cavity sealed
with temporary
filling
2nd visit: Root canals
irrigated, dried with
paper points and
filled using lateral
condensation with
gutta percha and
resin-based root
canal sealer

NOR, no occlusal reduction; OR, occlusal reduction; VAS, visual analogue scale.

percussion, as well as within 1 day of the treatment.
Conversely, OR reduces post-operative pain at 6-day fol-
low-up in teeth diagnosed with irreversible pulpitis. OR
is also likely to be beneficial in teeth presenting with
more severe tenderness to percussion associated with
irreversible pulpitis. Similarly, OR may be beneficial in
controlling post-operative pain related to symptomatic
apical periodontitis, but only in a limited number of
follow-up time points and in the absence of obvious
radiographic changes.
The most obvious limitation of this review is that only
seven studies were included, despite performing search
in three electronic databases, comprising DOSS, which
covers grey literature. Furthermore, the preoperative
pain status varied amongst the component studies, and,
due to the limited number of studies (i.e. three), further

© 2019 Australian Society of Endodontology Inc 9

Occlusal Reduction and Pain
Figure 2 Forest plot showing the post-operative pain between occlusal reduction and no occlusal reduction assessed at 6-day follow-up.
subgroup meta-analysis was not possible (with or with-
out pain). Additionally, amongst the three included stud-
ies included in the meta-analysis, three studies (37,39)
have not reported the preoperative pain status, whereas
one study (36) included teeth with mild pain. This
emphasises the need for future clinical trials to assess the
preoperative status using adequate pain scales (VAS or
numeric rating scale) prior to the randomisation process.
The use of different schedules and scales for the measure-
ment of pain made further statistical integration of the
results from the included studies impossible, with only
one (6 days post-operative) meta-analysis possible.
Therefore, the remaining findings were tabulated and a
narrative synthesis was carried out. Other limitations are
the questionable statistical power of some component
studies, absence of a comprehensive diagnosis (e.g. peri-
apical) in several studies, varying clinical protocols and
the broad differences in the schedules for post-operative
pain evaluation.
The role of occlusal contacts in the probability of
developing postendodontic pain has been previously
highlighted in the literature. Arias et al. determined
that the incidence of postendodontic pain following
single-visit root canal treatment was lower in the
absence of occlusal contacts (34). However, the large
reduction in post-operative pain due to endodontic
treatment itself, as well as the variation in pain expe-
rience amongst individuals, has been reported to
reduce the statistical power of clinical trials assessing
10
D. Nguyen et al.
pain treatment. This may explain why other studies
fail to detect any improvement in pain reduction or
only detect it in those patients with moderate-to-sev-
ere pain (41). Amongst the component studies of the
present review, three included subjects reporting sev-
ere pain (22,38,40), but only one (40) reported posi-
tive effects on post-operative pain after OR.
A major concern throughout the included studies was
the differences in selection criteria. For example, the use
of preoperative analgesia was stated as main exclusion
criteria in only two studies (21,40). There is good evi-
dence that use of pre-treatment analgesics may reduce
post-operative pain (42) and low-dose corticosteroid
treatment such as dexamethasone is also capable of min-
imising both post-operative inflammation and pain (43).
Studies included this review that did not exclude patients
already on pain relief medication may have confounded
pain assessment outcomes.
It should also be highlighted that apical diagnosis was
considered in only two studies (22,40). This is a potential
confounding factor not addressed in the remaining stud-
ies. The importance of accurate pulpal and periapical
diagnosis needs to be reiterated, considering that occlusal
reduction may be of importance in specific clinical condi-
tions. Interestingly, some of the studies stated ‘sensitiv-
ity/tenderness to percussion’, a common sign of apical
periodontitis, and ‘normal periapical radiographic
appearance’ as part of their inclusion criteria (21,36–39).
However, the absence of radiolucency and radiographic
© 2019 Australian Society of Endodontology Inc
D. Nguyen et al.
features associated with apical periodontitis in intraoral
radiographs does not necessarily guarantee a normal
periapical condition (44).
Differences in the chemo-mechanical preparation pro-
tocols also may be another potential confounding factor.
In fact, it was noted that in three of the included studies
canals were instrumented manually (36,38,39), whereas
four studies used rotary instrumentation (21,22,37,40).
Similarly, irrigation solutions also varied greatly between
the included studies with respect the concentration of
sodium hypochlorite used between instruments, which is
of particular significance in the presence of an inflamed
pulp as higher concentrations promote tissue dissolution
in vitro (45,46).
The use of intra-canal medicaments may also affect
post-operative pain. In one study, canals were dried and
left empty before access was closed with temporary filling
material (40). In this study, the patients also returned for
an obturation appointment for which pain was recorded
for 12 h post-operatively (40). Alternatively, calcium
hydroxide paste was also used as an intra-canal medica-
tion (21,36–39), whilst one study performed single-visit
root canal treatment (22). Single-visit treatment has been
associated with a higher frequency of late post-operative
pain (14).
A randomisation process was performed in all the stud-
ies. Furthermore, some studies (20–22,37,40) were
designed so that the operators performed occlusal reduc-
tion in the intervention groups and mock reductions in
the control groups. The sham reductions were performed
by activating the handpiece with copious water over the
tooth without touching the occlusal surface (21,22,37,40)
or by minimally adjusting a non-functional cusp whilst
still allowing the tooth to retain its occlusal contacts (20).
As no OR was done in the control group, knowledge of
the groups to the operator would not introduce any bias
and, hence, there was no possibility of bias due to absence
of allocation concealment. However, in studies where no
sham procedure for the control group was carried out
(36,38,39), the type of intervention would be known to
participants. Thus, there is a possibility of bias in the
domain of allocation concealment. Missing outcome data
in the control (without OR) group were higher (n = 6)
than the intervention (with OR) group (n = 2) in the
study by Parirokh et al. (21), and hence, the study was
scored as high risk of bias. The measurement of pain was
self-assessed by patients which prevents bias in measure-
ment of the outcome. Therefore, this criterion has been
scored as low risk of bias in all studies.
GRADE approach was used to evaluate the quality of
evidence from the summary measure derived from meta-
analysis. GRADE criteria on inconsistency and impreci-
sion were found serious due to high heterogeneity
© 2019 Australian Society of Endodontology Inc
Occlusal Reduction and Pain
(96.9%) and wide confidence interval of summary mea-
sures, respectively. The other criteria on risk of bias and
indirectness were not found serious. The final evidence
was found to be of ‘very low’ quality.
OR requires the removal of enamel or dentin from the
occlusal surface of the involved tooth; thus, the clinician
must consider the both efficacy and sequelae of OR as a
treatment approach. This loss of hard tissue may be suffi-
cient to alter the patient’s occlusal scheme and may war-
rant the need for further restoration. Moreover, mild
pain develops after instrumentation in 10%–30% of
cases whilst ‘flare-ups’ requiring emergency intervention
have been demonstrated in 3% of cases (2,47). Given
that post-instrumentation pain is generally at a level that
is both tolerable and temporary, any irreversible treat-
ment requires adequate justification. Finally, it should be
noted that only three of the included studies explicitly
listed suffering from bruxism and/or clenching as an
exclusion criterion (21,22,40). However, OR may be
more relevant in the endodontic treatment of patients
who exhibit occlusal parafunction and is diagnosed with
irreversible pulpitis or apical periodontitis.
One of the strengths of this systematic review is that
the included studies are all randomised clinical trials rep-
resenting the highest level of experimental evidence.
Furthermore, the protocol of this review was registered
in the PROSPERO database a priori.
Conclusions
OR following RCT likely reduces post-operative pain
associated with teeth diagnosed with irreversible pulpitis
and symptomatic apical periodontitis, in particular at 6-
day follow-up in cases of irreversible pulpitis. However,
OR has limited effect on pain reduction within the first
24 h after treatment. This review highlights the need for
further high-quality studies in order to better understand
the role of OR after root canal instrumentation for the
different pulpal and periapical diagnoses and subse-
quently provide more robust recommendations for clini-
cal practice.
Author contributions
All authors have contributed significantly, and all
authors are in agreement with the manuscript.
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Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1 Search strategy.
Table S2 Reasons for excluding the studies after full
text read.
Table S3 Risk of bias assessment for included studies.
Table S4 GRADE evidence profile.
13