Emergency treatment in teeth with symptomatic apical periodontitis

22 Pages·2013·0.32 MB·English

Emergency treatment in teeth with symptomatic apical
periodontitis

a randomized clinical study

Running title: Emergency treatment in teeth with symptomatic
apical periodontitis

Märta Stenberg

Handledare: Eva Wolf

Examensarbete (30hp) Malmö högskola
Tandläkarprogrammet Odontologiska fakulteten

Mars, 2013 205 06 Malmö
Abstract
The aim was to compare the pain relieving effect of complete chemo mechanical disinfection
of the root canal system with removal of necrotic tissue in the pulp chamber without
instrumentation of the root canals as emergency treatment in teeth with symptomatic apical
periodontitis.
The material consisted of 16 patients collected at the emergency clinic at Malmö University.
Patients with swelling and/or systemic involvement were excluded.
The patients were randomized to either treatment. The preoperative pain level and intake of
analgesics was registered. Three till 5 days postoperatively the patients were contacted and
asked to grade the current pain level and intake of analgesics and/or antibiotics.
The results showed that 100% of the patients treated with complete chemo mechanical
disinfection of the root canal system obtained satisfying pain relief compared to 71% for
patients treated with removal of necrotic tissue in the pulp chamber.
44% of the patients treated with chemo mechanical disinfection of the root canal system had
some kind of analgesics post-operatively compared to 29% for those treated with removal of
necrotic tissue in the pulp chamber. No patients in either group reported use of antibiotics
postoperatively.
The conclusion was that both complete chemo mechanical disinfection and removal of
necrotic tissue implied a significant pain relief as emergency treatment in teeth with
symptomatic apical periodontitis. There was no difference between the two treatments
concerning the number of patients who obtained sufficient pain relief or in pain relieving
effect.
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Keywords: symptomatic apical periodontitis, endodontic emergency treatment, infection,
necrotic, Numeric Rating Scale, pain relief

Sammanfattning
Syftet med denna masterstudie var att jämföra den smärtlindrande effekten av fullständig
utrensning och desinfektion av rotkanalsystemet med enbart utrymning av pulpakavum, utan
instrumentering av rotkanalerna, som akutbehandling hos tänder med symtomatisk apikal
parodontit.
Materialet utgjordes av 16 patienter insamlade på Tandvårdshögskolans jourmottagning.
Patienter med svullnad och allmänpåverkan exkluderades.
Patienterna valdes slumpmässigt ut till att genomgå någon av behandlingarna. Den
preoperativa smärtnivån och ev. analgetikaintag registrerades. Tre till fem dagar efter utförd
behandling kontaktades patienterna per telefon och fick då gradera sin postoperativa
smärtnivå samt analgetika- och/eller antibiotikaintag.
Resultatet visade att 100% av patienterna som behandlades med fullständig utrensning erhöll
tillfredställande smärtlindring jämfört med 71% av de patienter som behandlades med enbart
utrymning av pulpakavum. Skillnaden var inte statistiskt signifikant.
44% av patienterna som behandlades med fullständig utrensning hade tagit smärtstillande
postoperativt medan 29% av patienterna i utrymningsgruppen hade gjort det. Skillnaden var
inte signifikant. Ingen av patienterna oavsett behandling hade tagit antibiotika efter
behandlingen.
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Ingen skillnad förelåg i andelen patienter som blev tillräckligt smärtlindrade mellan
fullständig utrensning och enbart utrymning av pulpakavum hos tänder med symtomatisk
apikal parodontit. Det var inte heller någon skillnad i smärtsänkning mellan de två
behandlingarna.

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Background
The vital condition of the pulp is at risk as a result of micro-organisms and their toxins. They
can reach the pulp, most commonly through dental caries, but also by fractures of the dental
hard tissues and/or leaking restorations. The early response of the pulp is an inflammation that
eventually will lead to necrosis of the pulp (1). A necrotic pulp offers a favorable environment
for bacteria and allows them to aggregate and form resistant biofilms (2). Although the oral
microflora consists of more than 300 bacterial species, only few of them are able to infect the
necrotic pulp and survive (3).
Apical periodontitis is the inflammatory response in the periapical tissues against a bacterial
infection situated in the root canals of a tooth and may also induce a destruction of the
surrounding bone. A study performed on monkeys showed that bone lesion could only
develop when an infection was present in the necrotic tooth and not when the tooth was
necrotic but non infected (4).
Acute pain from a vital or necrotic tooth is a frequent occurrence in the endodontic practice
(5). Often the available time to perform the treatment is limited due to an already fully booked
calendar and so the purpose of the emergency treatment in these patients is to reduce the pain
to an acceptable level as efficient as possible.
A number of studies have been made to find the best and most cost effective emergency
treatment options for acute symptoms rising from vital and necrotic teeth. This includes
removal of the inflamed or necrotic tissue in the pulp chamber, complete chemo mechanical
disinfection of the root canal system and systemic antibiotic treatment alone or in combination
with other treatments (6-8). A range of studies have shown good result for pulpotomy as
emergency treatment in symptomatic vital teeth with approximately 90% of the treated
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patients obtaining pain relief post-operatively. The pain relief was measured as completely
free of symptoms, mild post-operative pain or low return frequency for additional treatment in
the different studies made on this topic (9-13). This result is comparable with those of
complete chemo mechanical disinfection of the root canal system in vital teeth, but pulpotomy
can be seen as a more cost effective option at the acute situation because of a shorter
treatment time needed (11, 13-14).
Systemic antibiotic as symptomatic treatment in vital teeth is considered non-adequate. This is
due to that the infection is located in the hard tissues of the tooth (dental caries) and so
antibiotics can't reach it to with the blood stream to eliminate it (15). However, systemic
antibiotic treatment alone has been found to have a pain relieving effect in patients with a
symptomatic necrotic tooth (6), while antibiotics as additional treatment to complete chemo
mechanical disinfection of the root canal system was found to have no additional effect on
pain relief (7-8).
Considering removal of necrotic tissue in the pulp chamber, Molander et al. (2004)(12),
showed in a prospective study with 76 patients that the pain relief in necrotic teeth was
considered sufficient in approximately 75% of the patients. In a retrospective study with 2184
patients, Bjerkén et al. (1980)(13) found a return frequency of 25% within 10 days in patients
treated with only removal of necrotic tissue in the pulp chamber, compared to a 9% return
frequency among patients receiving a complete disinfection of the root canal system at the
emergency treatment occasion.
Other studies showed that 73-89% of patients treated with complete chemo mechanical
disinfection obtained pain relief post-operatively. Many of them required though a post-
operative intake of peripheral analgesics (7-8, 16).
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Very few studies can be found which investigate emergency treatment in necrotic teeth and no
randomized controlled clinical study could be found in which the pain relieving effect of a
complete chemo mechanical disinfection of the root canal system is compared to the removal
of necrotic tissue in the pulp chamber but without instrumentation of the root canals.
The aim of this prospective, randomized clinical study was to compare complete chemo
mechanical disinfection of the root canal system with removal of necrotic tissue in the pulp
chamber but without instrumentation of the root canals as emergency treatment in teeth with
symptomatic apical periodontitis, with the outcome measure pain relief. The expected result
and hypothesis was to find that the root canal infection as the etiological factor of the
experienced pain must be completely eliminated by complete chemo mechanical disinfection
in order to achieve a satisfying pain relief in a majority of patients.

Material and methods
Subjects
The study included consecutive adult patients attending the emergency clinic at the Faculty of
Odontology, Malmö University, Malmö, Sweden during March-October 2012, where they
were clinically diagnosed with a symptomatic apical periodontitis.
The patients reported spontaneous pain and/or pain on percussion and palpation of the area.
The patients graded their pain from 0-10 on the Numeric Rating Scale (NRS), and those who
graded their pain with NRS >3 were included in the study. Included patients were also
required to have the possibility to return to the clinic within two weeks and accepted to be
contacted by phone within 3-5 days after the emergency treatment.
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Those patients where the current tooth had received previous endodontic treatment and those
where additional treatment with antibiotics or incision would be needed were excluded.
Indications for antibiotics and/or incision were intra- and/or extra oral swelling and fever as
an indicator of systemic involvement.
Treatment
The examinations and the following treatments were executed by general or specialized
dentists or by supervised undergraduate students at the emergency clinic.

The patients were randomized using a randomization chart made in Microsoft Office Excel
2007 with numbers from 1-1000, to be treated either by removal of necrotic tissue in the pulp
chamber (odd numbers) but without instrumentation of the root canals (RNT) or by complete
chemo mechanical disinfection (even numbers) of the root canal system (CMD).
Excavation of present caries was made in all the symptomatic teeth when necessary and an
access preparation was made with the purpose to expose all root canal entrances.
The RNT treatment was performed without the use of rubber dam and the pulp chamber was
cleaned from necrotic and infected tissue with the rinse of non sterile water. The patients were
scheduled for a new appointment within two weeks after the treatment for complete chemo
mechanical disinfection of the tooth.
The CMD treatment was performed with the use of rubber dam. The working area had to be
well isolated without leakage from the oral cavity. The tooth and the rubber dam clamp were
disinfected with a 30% solution of hydrogen peroxide (APL, ApotekProduktion&Laboratorier
AB) while the entire field of operation including tooth, clamp and rubberdam was disinfected
with a 0,5% chlorhexidine-alcohol (Fresenius Kabi). The root canals were cleaned and shaped
using the crown-down concept with K3 rotary instrumentation (Dentsply, DeTrey GmbH,
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Konstanz, Germany) and/or manual instruments following the ISO-standardization, till
adequate size where necrotic tissue as well as infected dentin was removed, depending on the
size of the root canal. The chemical rinse consisted of an irrigation with 0,5% buffered NaOCl
solution(Dakin’s solution) and a 15% ethylenediaminetetraacetic acid (EDTA) solution (APL,
ApotekProduktion&Laboratorier AB). Calcium hydroxide was the temporary dressing in the
root canals. After the treatment, all the teeth were sealed with a temporary filling of zinc
oxide-eugenol cement (ZOE) and a glass ionomer cement( Ketac™ Fil, 3M ESPE Dental
Products, Germany).
All patients were contacted by phone 3-5 days after the emergency treatment and were
reminded of their pre-operative grading on NRS and were then asked to grade their current
post-operative pain according to NRS. Patients with NRS ≤ 3 post-operatively were
considered satisfying pain relieved. Their possible post-operative use of analgesics and
antibiotics was registered.
Power analysis
A statistical power analysis was conducted using parts of the data from one study (Bjerkén et
al. 1980) (13) that had evaluated both complete chemo mechanical disinfection and removal
of necrotic tissue in the pulp chamber. With two groups, each consisting of 95 test subjects,
the chances of obtaining a statistically significant result is 80%, if there is a difference of
16,5% (90,5% vs 74%) between the groups.
Statistics
For the calculations the Predictive Analytic SoftWare (PASW) Statistics 18 was used. The
statistical method of 2x2 tables was the Chi square test or Fisher's exact test when the
proportions were small and the expected value < 5. The calculations were two-tailed. Results
were considered statistical significant at p < 0.05.
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Ethical considerations
An ethical consideration concerning leaving necrotic and infected tissue in a tooth was made.
By informing the patients about possible consequences, giving them a new appointment for
removal of the necrotic tissue, this was considered enough to keep the patient's state under
control. Patients were also welcome to contact the clinic for additional treatment if needed
before scheduled appointment.
The study was approved by the Local Ethical Review Board at the Faculty of Odontology,
Malmö University, Malmö Sweden according to the World Medical Association (WMA)
Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects
(17). The patients also signed an informed consent before they participated in the study.

Results
There were 19 patients included in the study. Three patients were drop-outs, two women and
one man between 46 and 75 years old with the average age of 59.3 years old. The cause was
non-accessible and/or narrow root canals and so the pre-determined treatment was not
possible to execute at the first treatment occasion.
There were nine patients treated in the CMD group and seven patients in the RNT group. Five
of the patients were men, 11 were women. The patients were between 23 and 88 years of age.
The average age of the treated patients was 48.5 years.
Dental students performed the treatment in four patients in the CMD group and in four
patients in the RNT group while dentists performed the treatment in five patients in the CMD
group and in three patients in the RNT group.
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