The Journal of the Australian Society of Endodontology Inc.

and the Australian and New Zealand Academy of Endodo ntists

Aust Endod J 2009; 35: 8992

ORIGINAL RESEARCH

Postoperative pain and associated factors in adolescent patients undergoing two-visit root canal therapy
Patrcia de Andrade Risso, DDS, MS1; Antonio Jos Ledo Alves da Cunha, MD, PhD2; Marcos Csar Pimenta de Araujo, DDS, PhD3; and Ronir Raggio Luiz, DSc, PhD4
1 2 3 4 Department of Medical Clinic, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Department of Dental Clinic, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Institute of Studies of Public Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

Keywords adolescent, endodontics, pain, postoperative, pulp necrosis, root canal therapy. Correspondence Patrcia de Andrade Risso, Department of Medical Clinic, School of Medicine, Federal University of Rio de Janeiro, Rua: Presidente Joo Pessoa, 164/802 Icara, Niteri RJ 24230-331, Brazil. Email: risso.p.a@gmail.com doi:10.1111/j.1747-4477.2008.00134.x

Abstract
This prospective study investigated the frequency and intensity of postoperative pain and identied associated factors in adolescents undergoing two-visit root canal therapy. Sixty-four patients aged 11 to 18 years old presenting with molars with pulp necrosis were assigned consecutively to two visits (plus an interappointment dressing using calcium-hydroxide paste). Pain intensity was recorded on a visual analogue scale (VAS) of 05. Data were analysed using multivariate logistic regression. The frequency of postoperative pain was 32.8% (21/64), with intensities of VAS 1 and VAS 2 in 81%, VAS 3 in 14.3% and VAS 4 in 4.7% of the 21 cases in which it was experienced. Spontaneous preoperative pain (odds ratio (OR) = 6.60; 95% condence interval (CI) = 1.6126.97; P = 0.009) and absence of apical perodontitis (OR = 5.65; 95% CI = 1.3423.87; P = 0.01) were associated with postoperative pain. The frequency of postoperative pain was high, but the intensity, in general, was low, including are-ups. The presence of spontaneous preoperative pain and absence of apical periodontitis increase the probability of suffering from postoperative pain. Risk factors have been associated with postoperative pain, namely the presence and degree of apical periodontitis (69), preoperative sinus (6), pulp necrosis (6,8), spontaneous preoperative pain (1,8), percussive preoperative pain (9), re-treatment (10), sex (6,8,10) and age (1,11). Nevertheless, frequency and factors exclusively associated with postoperative pain in young patients have been poorly investigated. Thus, the objective of this study was to investigate the frequency and intensity of postoperative pain, and identify associated factors in adolescents undergoing two-visit root canal therapy.

Introduction
Pain and fear of pain are serious problem in the dentist patient relationship. Pain is the main reason that patients seek odontologic treatment (1). This relationship has been perpetuated for several generations, as adults continue with the same custom for the adolescents under their charge, that is, they only take their children to the dentist in cases of pain (2). The prevalence of toothache is proportionally high among adolescents, even in populations known to have a low incidence of dental caries (3). This pain is most often associated with inammation of pulpal or periradicular tissues (4). Hence, a successful dentistpatient relationship can be measured by both the treatment and pain prevention following an intervention. Even so, some degree of pain is usually expected after endodontic treatment and the possibility of severe pain, although unlikely, is of concern (5).

Patients and methods

The present study is an extension of an in-course study on one-visit vs. two-visit endodontic therapy to prevent and repair apical periodontitis in adolescents. This study was approved by the local Research Ethics Committee,
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and each subject participating in this study, along with their parents, signed detailed informed consent forms. Data regarding root canal therapy of 64 teeth of 64 patients who had been referred to the Endodontic Clinic at the School of Dentistry were evaluated. The patients had to be otherwise healthy, could not have taken analgesic, anti-inammatory or antibiotic drugs during the 10 days prior to the start of treatment, aged between 11 and 18 years old, with lower rst or second permanent molars presenting complete root formation and necrotic pulp (cold pulp test) with or without symptoms, and absence of periodontal disease, pulp calcication, or acute dentoalveolar abscesses. Each patient was anaesthetised with local anaesthetic solutions (long-acting local anaesthetics were not used). Preparations of the root canal were performed by the rst author during the patients rst visit, and carious lesions and leaking restorations were also removed. The rubber dam was positioned, the operative eld decontaminated with 5.25% sodium hypochlorite (NaOCl) and neutralised with 5% sodium thiosulphate (Na2S2O3). Access (no hemorrhage was observed) was completed using a separate set of sterilised instruments and distilled water, and a sample for microbiological culture (thioglycolate) was collected prior to the treatment. Chemomechanical preparation was achieved using middle-coronal prearing (initial passive step-back instrumentation was performed to facilitate the use of Gates Glidden burs, as well as to direct their cutting action to up to 3-mm from radiographic apex). The working length was established at the radiographic apex (apex locator with conrmation by radiography). Apical preparation was completed using step-back in 1-mm increments. Irrigation was always performed using 5.25% NaOCl solution. The root canals were irrigated with 10% citric acid followed by 5.25% NaOCl to remove smear layer. Next, the irrigating solutions were buffered with 5% Na2S2O3 so that postpreparation microbiological cultures could be performed. Subsequently, the root canals were lled with calcium hydroxide paste and distilled water (1:1) using a Lentulo spiral with conrmation by periapical radiography. Medication was kept in the canal for 1012 days. Postoperative pain was measured using a visual analogue scale (VAS) of 0 (no symptom) to 5 (severe pain and/or swelling) (12,13). Following the visit, the patients received written details of the scale, as well as a questionnaire to report their pain over a 10-day period. Evaluation of the frequency of pain was determined by the rst annotation after the visit as follows: yes (VAS ranging from 1 to 5) and no (VAS = 0), and the pain intensity considered was the highest score recorded over the evaluation period. VAS equal to 4 or 5 were regarded as are-up. Data on the following characteristics were collected: age, sex,
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spontaneous preoperative pain, percussive preoperative pain, preoperative sinus, apical periodontitis (14), root canal exposure to oral environment and microbiological culture post-chemomechanical preparation. The relationship between clinical factors and postoperative pain was analysed using odds ratio (OR) and logistic regression models based on bivariate and multivariate analyses (P < 0.05). The probability of pain was determined for the signicant variables. The SPSS statistical software (version 11.0, SPSS Inc., Chicago, IL, USA) was used.

Results
The sample consisted of 64 study patients (56.3% women; mean age = 13.6 years; SD = 2.84 and median age = 12.8 years). The preoperative cultures were positive in 100% of the patients. Cases of preoperative spontaneous pain had a VAS equal to 1. Some degree of postoperative pain occurred in 32.8% (n = 21) of the cases. Pain intensity was found to be low, as of the 21 patients who presented with pain, 17 (81%) reported VAS 1 (taking no medication) or VAS 2 (taking one tablet of paracetamol), 3 (14.3%) related VAS 3 (taking two tablets of paracetamol at a 6-h interval) and 1 (4.7%) reported VAS 4 (taking one tablet of paracetamol every 6 h during 3 days). As cases with VAS 4 and 5 were regarded as are-up, the frequency of are-up was 1.56% (1/64). Frequency and degree of postoperative pain were higher during the rst 24 h. The variables were individually analysed as shown in Table 1. Based on the bivariate analysis, variables presenting P-values 0.20 were included in a logistic regression model (15). In this case, spontaneous preoperative pain (OR = 5.33; 95% condence interval (CI) = 1.2422.80; P = 0.024) and apical periodontitis (OR = 8.07; 95%CI = 1.7537.13; P = 0.007) were statistically

Table 1 Relationship between clinical factors and postoperative pain: bivariate analysis Variables Sex (female) Age (1518 years) Preoperative pain spontaneous Preoperative pain pericemental Apical periodontitis (No) Preoperative sinus Exposure to oral environment Culture post-chemomechanical preparation (positive) OR 0.79 0.82 4.67 2.18 3.80 4.42 0.70 1.78 95% CI for OR 0.272.26 0.262.59 1.2916.86 0.726.57 1.0313.95 0.3751.79 0.232.10 0.427.50 P-value 0.66 0.74 0.01 0.16 0.03 0.20 0.52 0.42

OR, odds ratio; CI, condence interval.

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Table 2 Relationship between clinical factors and postoperative pain: multivariate logistic regression analyses Variables Apical periodontitis (No) Preoperative pain spontaneous Preoperaive pain pericemental Preoperative sinus OR 8.07 5.33 2.26 2.06 95% CI for OR 1.7537.13 1.2422.80 0.559.36 0.1234.73 P-value 0.00 0.02 0.25 0.61

OR, odds ratio; CI, condence interval.

Table 3 Probability of occurring postoperative pain according to presence or absence of the following factors: apical periodontitis and spontaneous preoperative pain Spontaneous preoperative pain Yes Apical periodontitis Yes No 59% 91% No 16% 60%

associated with postoperative pain (Table 2). The new model was tested using logistic regression to identify an interaction involving spontaneous preoperative pain (OR = 6.60; 95% CI = 1.6126.97; P = 0.009) and apical periodontitis (OR = 5.65; 95% CI% = 1.3423.87; P = 0.01), which remained statistically associated with postoperative pain. However, the variables showed no interaction. The probability of postoperative pain occurring in respect to these variables is shown in Table 3.

One limitation of this study is the relatively small number of endodontically treated teeth in the sample. However, the present study is the only one to carry out this type of approach with adolescent patients, involving only molar teeth. Although controversial, some studies (20,23) have suggested that postoperative pain is more likely to occur in molar teeth. Bivariate analysis and logistic regression were performed to select the variables to be included in the nal logistic regression model and assess the possibility of interactions. The existence of postoperative pain was associated with the presence of spontaneous preoperative pain and the absence of apical periodontitis. Studies have shown that the presence of preoperative pain can signicantly increase the probability of postoperative pain (1,810). However, the inuence of apical periodontitis on the frequency of postoperative pain is inconclusive. Our results demonstrated that teeth without apical periodontitis are more susceptible to postoperative pain, which is in agreement with some previous studies (10,19), but not all (9). In the present study, the probability of postoperative pain occurring in teeth presenting with spontaneous pain but without apical periodontitis was 5.6 times greater than in those presenting with apical periodontitis and no spontaneous preoperative pain. The increased probability of postoperative pain in teeth without apical periodontitis might be justied by the lack of space for pressure release when periradicular bone resorption is absent (19).

Discussion
The frequency of postoperative pain was consistent with that reported by other authors (1618), although disagreement was found elsewhere (19,20). The intensity was found to be low, including are-ups. The frequency of are-ups is supported by some previous studies (19,21), however differs from others (20,22). Any comparison with other studies should be cautiously viewed because of differences regarding the study design, preoperative status of teeth, treatment protocols, including intracanal medication and demographic characteristics, in particular the patients ages, as other studies usually only included over 18-year-old patients (16,18,19,21), and different methods for collecting and analysing the data on postoperative pain. Different scales and methods have been used for the assessment of postoperative pain. Among them, the VAS is considered to be a valid, reliable and the best scale to measure the pain in adolescent patients (12). The VAS scores were grouped into six categories (ranging from 0 to 5) in order to facilitate data reading and to allow greater clinical relevance (13).

Conclusion
The ndings in this study suggest that the frequency and intensity of postoperative pain in adolescents were similar to those reported in previous studies involving adult patients and are inuenced by both the absence of apical periodontitis and the presence of spontaneous preoperative pain.

Acknowledgement
This study was supported by Brazilian grants from CAPES and FAPERJ (E-26/170.575/2005 and E-26/100.018/06).

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