PAIN IN ENDODONTICS

Pain related to endodontics is both annoying and perplexing problem to the patient as well as dental surgeon

Though the pain may not be a sign of endodontic failure relieving pain is off utmost importance.

The causative factors of interappointment pain comprise

mechanical, chemical, and/or microbial injury to the pulp

or periradicular tissues, which are induced or exacerbated

during root canal treatment

The intensity of the inflammatory response is directly

proportional to the intensity of tissue injury

Mechanical and chemical injuries are often associated with

iatrogenic factors, but microbial injury is arguably the

major and the most common cause of

interappointment pain

RATIONALE FOR PAIN IN ENDODODNTICS Periapical extrusion of debris Vigorous instrumentation beyond the root apex an

lead to pain

Thorough recapitulation and proper irrigation of root canals prevents post operative pain

Apical Extrusion Of Debris

If during chemomechanical preparation

microorganisms are extruded into the periradicular

tissues, the host will face a situation in which it is

now challenged by a larger number of irritants than

it was before. Consequently, there will be a transient

disruption in the balance between aggression and

defense, in such a way that an acute inflammatory

response is mounted to re-establish equilibrium.

Incomplete instrumentation of root canal Incomplete chemomechanical preparation can

disrupt the balance within the microbial community by eliminating some inhibitory species and leaving behind other previously inhibited species, which can then overgrow.

If overgrown strains are virulent and/or reach sufficient numbers, damage to the periradicular tissues can be intensified and then result in lesion exacerbation.

Incorrect measurement of root canal length – may cause post operative pain

Instrumentation before measurement of root canal

Proper angulated x rays and apex locators help in attaining the exact working length of the root canal.

Keeping the canal empty for long time after instrumentation will cause periapical flow of bacteria

Continous hyperocclusion from the temporary filling will cause periapical injury causing post operative pain

Empty root canal

Crack of septa- between two closely placed canals from overzealous instrumentaion leads to post operative pain

Eg- mandibular molars-distal roots , mesiobuccal roots of upper molars

Pulpal tissue in the isthmus region of upper molars and lower molars is difficult to be eradicated as thus causes pain

60% of mesiobuccal roots of upper molars and 30% of distal roots of lower molars have isthmus which is difficult to remove.

Endodontic irrigation with hydrogen peroxide or sodium chloride beyond the apex leads to post operative pain. Nascent oxygen remains beyond tooth closure and can cause pain

Silver cone obturation causes microleakage and corrosion of the metal causing pain.

More pain can also occur after lateral condensation when compared to single cone technique

Missed canals in the mandibular molars and maxillary centrals can cause severe post operative pain

Invaginated tooth and deep palatogingival groove in incisors can lead to pain if improperly treated

Invaginated toothMissed canal Palato gingival groove

Calcified canals- canals which are calcified will have microscopically bacterial passage through narrow spaces and can cause pain

Single visit endodontics- flare ups and pain can occur if treatment plan fails

Other reasons are 1. patients with mobile teeth 2. low threshold for pain-emotional problems like

tension and depression 3.patients with low immunity 4.unknown reasons 22% of cases fail because of poor case selection Eg- poor restorability of tooth, unnegotiable canals,

root resorption, medically compromised patient, separated instruments

Clinical Measures To Improve Success

Success rests on well planned and executed stepsRubber dam application-asepsis, prevents aspiration of instrumentsAvoid insulting periapical tissues by instruments, debris and filling materialsProper working length determinationDisocclude the tooth whenever necessary Through irrigationDiscard when flutes open up or disturbedUse of vision enhancing devices- magnifying lens, microscopes