Title	Surgical Trephination as an Adjunct to Endodontic Therapy Not Shown to Reduce Post-Operative Pain
Clinical Question	When performing endodontic therapy on a tooth, does surgical trephination reduce a patient’s postoperative pain when compared to no trephination?
Clinical Bottom Line	There is no current evidence indicating that the use of surgical trephination as an adjunct to endodontic therapy helps to reduce post-operative pain.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 11487138 Nist/2001 50 Emergency patients Randomized Controlled Trial Key results Over the 7-day observation period, both groups (trephination/mock trephination) saw a general decrease in postoperative pain and percussion ratings. There were no statistically significant differences in postoperative pain and percussion ratings between the trephination and mock trephination groups. There was no statistical difference in the number of ibuprofen taken, but patients with trephination did take significantly (p < 0.05) less acetaminophen with codeine over the 7-day observation period. 11027389 Houck/2000 50 Emergency patients Randomized Controlled Trial Key results There was no statistically significant difference between the two groups (trephination/mock trephination) for the “sum pain intensity difference” (P = .3312). Both groups saw a general decrease in the mean postoperative pain ratings over the 7-day observation period. No statistically significant difference was observed over the 7-day postoperative observation period for the mean total number of ibuprofen (P = .1366) and acetaminophen with codeine (P = .6797) tablets taken. 8941752 Moos/1996 17 Patients with pre-treatment pain Randomized Controlled Trial Key results The group receiving trephination reported significantly greater pain intensity (p = 0.025) and unpleasantness (p = 0.013) than the control group at 4 hours post operatively. Similarly, the trephination group reported significantly less pain relief at 4 hours post operatively than the pulpectomy group without trephination (p = 0.007). The two groups showed no difference in the need for analgesics.
Evidence Search	("tooth"[MeSH Terms] OR "tooth"[All Fields]) AND ("trephining"[MeSH Terms] OR "trephining"[All Fields] OR "trephination"[All Fields]) AND ("pain, postoperative"[MeSH Terms] OR ("pain"[All Fields] AND "postoperative"[All Fields]) OR "postoperative pain"[All Fields] OR ("postoperative"[All Fields] AND "pain"[All Fields]))
Comments on The Evidence	Validity: Both the first and second studies were well designed in that they both had a sufficiently large sample size of 50 patients who were randomly and evenly distributed between groups receiving trephination and no trephination. The patients in these two studies were also blinded by having one group receive a mock trephination, thus adding to the validity of its evidence. The first two studies also confirmed that there were no statistical differences pre-operatively among variables (age, gender, lesion size, etc.), indicating that both groups (trephination/mock trephination) were representative of the same population. Preoperative pain was also assessed in all three studies, which increases their validity compared to some earlier studies that neglected to record preoperative pain. Realizing that analgesic use could affect the pain score reported by patients postoperatively, recording the number and type of analgesics used by patients as an additional marker added to the robustness of all three clinical designs. The last study by Moos et. al. could have benefited from a larger sample size and the number of patients in each group were not evenly distributed. The group receiving only pulpectomies consisted of 11 patients, almost double that of the group receiving pulpectomy in combination with surgical trephination. Despite this uneven distribution, a positive aspect was that there was no significant difference in reported pain between the groups preoperatively. Perspective: Though the first study did find that the trephination group took significantly less acetaminophen with codeine, there were no significant differences in ibuprofen usage and they also found trephination did not initially reduce postoperative pain to clinically manageable levels. All 3 studies only included patients that were symptomatic and had pain prior to the procedure. This was an astute use of inclusion criteria since practitioners will most likely only use trephination, if at all, on patients presenting with moderate to severe pain.
Applicability	Surgical trephination was a procedure advocated by Guttman and Harrison (1991) as being beneficial in patients with moderate to severe pain without any visible intra-oral or extra-oral swelling. The use of trephination has diminished over time, which can possibly be attributed to a perceived increase in procedural time or perhaps an impression that it is not a clinically useful procedure in reducing pain. In fact, the third article found that the group receiving pulpectomy with trephination reported significantly increased post-operative pain and unpleasantness at the 4-hour mark when compared to pulpectomy alone. The trephination procedure is also not without morbidity as evidenced by the third study in which two patients exhibited a firm submucosal swelling beneath the closed incision site. As a whole, these well-designed prospective randomized controlled trials found no significant reduction in pain when using a trephination procedure. Given the lack of evidence for pain reduction, in combination with possible morbidity associated with the procedure, prophylactic trephination should not be considered a routine treatment modality.
Specialty	(Endodontics) (General Dentistry)
Keywords	endodontic, trephination, postoperative pain
ID#	3109
Date of submission	11/10/2016
E-mail	giacomino@livemail.uthscsa.edu
Author	Christin Michelle Giacomino, DDS
Co-author(s)
Co-author(s) e-mail
Faculty mentor	James A. Wealleans, DMD
Faculty mentor e-mail	James.Wealleans@us.af.mil; Wealleans@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available