ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title In Patients Undergoing Nonsurgical Root Canal Treatment, Occlusal Reduction Helps to Reduce Post-endodontic Pain
Clinical Question Does occlusal reduction effectively reduce post-operative endodontic pain in patients undergoing nonsurgical root canal treatment (NSRCT) for symptomatic irreversible pulpitis and with/without symptomatic apical periodontitis as compared to no occlusal reduction?
Clinical Bottom Line In patients undergoing nonsurgical root canal treatment, occlusal reduction reduces post endodontic pain. In patients undergoing nonsurgical root canal treatment having symptomatic irreversible pulpitis and with/without symptomatic apical periodontitis occlusal reduction helps reduce post endodontic pain at 72 hours and later. This is supported by two systematic reviews and meta-analysis of several randomized controlled trials in which occlusal reduction clearly helps reduce post endodontic pain at 72 hours and later. However, results should be interpreted with caution as studies included in these systematic reviews were heterogeneous. There is a need for further research to minimize the effect of confounding factors and less heterogeneous studies.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 31880822 Shamszadeh/2020 Six randomized controlled trials including 344 participants Meta-Analysis
Key resultsEfficacy of occlusal reduction in post-endodontic pain control had a positive influence on day 3 after NSRCT in the control of post-endodontic pain. However, conclusion should be considered with caution because of the methodological heterogeneity between the trials and small number of studies.
#2) 31638301 Nguyen/2020 Three randomized controlled trials including 762 participants Meta-Analysis
Key resultsOcclusal reduction following NSRCT reduces post-operative pain associated with teeth diagnosed with irreversible pulpitis and symptomatic apical periodontitis, particularly at 6-day follow-up in cases of irreversible pulpitis. However, occlusal reduction has limited effect on pain reduction within the first 24 h after treatment.
#3) 32418236 Ahmed/ 2020 308 patientsRandomized Controlled Trial
Key resultsOcclusal reduction was effective in reducing the intensity of postoperative pain 12 h and 24 h after root canal instrumentation at the first visit in patients with symptomatic irreversible pulpitis with sensitivity to percussion.  
Evidence Search The MeSH terms used were (endodontics OR root canal therapy OR root canal OR pulpitis OR apical periodontitis) AND (postoperative pain OR post endodontic pain OR pain) AND (occlusal reduction OR occlusal relief OR occlusal adjustment).
Comments on
The Evidence
In Shamszadeh/2020, the research question was precisely mentioned in the title of this paper and study selected randomized placebo-controlled trials. The study included a table identifying the included studies with the number of patients and related pre-operative teeth diagnosis. Shamszadeh/2020 included symptomatic irreversible pulpitis with or without apical periodontitis studies involving rotary and manual instrumentation studies up to the year 2019. A systematic search was performed through MEDLINE via the PubMed, the Cochrane Library, Scopus and Google Scholar, limited to English-language publications only. There were no publication date restrictions. They did not include articles published in other languages so they may have missed some studies related to the topic. Titles and abstracts of the papers included were evaluated independently by two reviewers. After removing irrelevant or duplicated papers, full texts were reviewed. Any disagreements were resolved through discussion with a third reviewer. They had very precise criteria for the selection of studies: studies were included if they were RCTs comparing the efficacy of occlusal reduction with placebo in decreasing post-operative endodontic pain and population were defined as adults (>15 years old) who had undergone primary root canal therapy in posterior maxillary/mandibular teeth with diagnosis of either irreversible pulpitis or pulpal necrosis. Based on Shamszadeh/ 2020, Efficacy of occlusal reduction in post-endodontic pain control had a positive influence on day three after NSRCT in the control of post-endodontic pain. However, conclusion should be considered with caution because of the methodological heterogeneity between the trials and small number of studies. In Nguyen/2020, research topic was clearly mentioned in the title of the paper. Electronic searches were performed on PubMed (MEDLINE), Dentistry & Oral Sciences Source (DOSS) and the Cochrane Library databases including articles published from inception through to 15 October 2018. They also used a wide variety of search terms. Their inclusion criteria were precise, and they have a nice table mentioning reasons for rejection of a particular study. After the initial screening process, the total number of studies included was 7 with population samples ranging from 35 to 402, which may be a limitation as publication bias through funnel plot was not examined. According to Nguyen/2020, occlusal reduction following NSRCT likely reduces post-operative pain associated with teeth diagnosed with irreversible pulpitis and symptomatic apical periodontitis, particularly at 6-day follow-up in cases of irreversible pulpitis. However, occlusal reduction has limited effect on pain reduction within the first 24 h after treatment. Ahmed/2020, research topic is clearly mentioned in the title of the paper. Sample size estimation was performed based on a type I error (α) of 0.05 and a power set at 98%. They used block randomization to allocate patients to either group. Inclusion and exclusion criteria are well mentioned in the study. They have followed all the criteria to validate this study as randomized controlled trial. They used all the appropriate statistical tests for the data evaluation. Their data was coded to blind the statistician. The significance level was set at P = 0.05. Based on this study, occlusal reduction was effective in reducing the intensity of postoperative pain 12 h and 24 h after root canal instrumentation in the first visit in patients with symptomatic irreversible pulpitis with sensitivity to percussion.
Applicability Nonsurgical root canal treatment is aimed at eliminating pain of endodontic origin. However, post endodontic pain after endodontic treatment has been reported in 25%-40% of all endodontic patients at day 1 and about 11% after 1 week (Nixdorf, 2010). The use of occlusal reduction can help reduce post endodontic pain in patients having symptomatic irreversible pulpitis and with/without symptomatic apical periodontitis.
Specialty/Discipline (Endodontics) (General Dentistry)
Keywords Occlusal reduction, Occlusal adjustment, Post endodontic pain, pain relief, post treatment pain, root canal therapy, endodontic treatment, root canal, symptomatic irreversible pulpitis, symptomatic apical periodontitis
ID# 3503
Date of submission: 11/26/2022spacer
E-mail ganatras1@livemail.uthscsa.edu
Author Shilpa Ganatra, BDS
Co-author(s) Noorpreet Kaur, BDS, MPH
Co-author(s) e-mail kaurn1@uthscsa.edu
Faculty mentor/Co-author Nikita Ruparel, DDS, PhD.
Faculty mentor/Co-author e-mail ruparel@uthscsa.edu
Basic Science Rationale
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