EFFICACY OF ENDODONTIC DEBRIDEMENT ON POSTOPERATIVE PAIN IN SYMPTOMATIC TEETH WITH PULPAL NECROSIS A Thesis Presented in Partial Fulfillment of the Requirements for the Degree of Master of Science in the Graduate School of The Ohio State University By Raquel D. Sebastian, D.D.S. Graduate Program in Dentistry The Ohio State University 2014 Master’s Examination Committee: Melissa Drum, D.D.S., M.S., Advisor Al Reader, D.D.S., M.S. John Nusstein, D.D.S., M.S. Sara Fowler D.M.D., M.S. F. Michael Beck, D.D.S., M.A Copyright by Raquel D. Sebastian, D.D.S. 2014 ABSTRACT Patients without a general dentist or access to dental care often present to a hospital emergency department with painful teeth. These patients are typically prescribed pain medication and an antibiotic until they can be evaluated and treated by a dentist. There are currently no studies to demonstrate if initial root canal debridement is better than just placing the patient on medications for pain relief during this symptomatic period. The purpose of this study was to compare initial endodontic treatment versus no initial endodontic treatment for postoperative pain in patients with symptomatic teeth with a pulpal diagnosis of necrosis and associated periapical area. Ninety-five patients presenting for emergency endodontic treatment experiencing moderate to severe pain were analyzed in the study. The patients were randomly divided into two groups: an initial debridement group who received anesthetic and emergency endodontic treatment, and a second non-debridement group who received anesthetic, but no initial debridement. At the end of the appointment, patients were given ibuprofen (600mg q6h) and acetaminophen (500mg q6h) and a prescription for an antibiotic. Patients also received a 5-day diary to record their pain level and the amount of pain medication taken. Postoperative data was analyzed using multiple Mann-Whitney-Wilcoxon tests and the Step-down Bonferroni method of Holm. Results showed that for both the debridement and the non-debridement groups, the level of pain reported decreased over the course of ii the five days. However, there were no significant differences between the two groups until day 5. Both groups showed a decrease in medication usage over the 5-day period. There was no significant difference between the two groups with respect to escape drug use. Twenty percent of patients in the debridement group and 12% of patients in the non- debridement group utilized an escape drug. iii DEDICATION To my Mom, who I am convinced prayed me through this residency. You inspire me every day with your strength and wisdom. Thank you for teaching me the important things in life and for being not only a mother, but a friend. To my Dad, whose endless love and encouragement is unmatched. Thank you for everything you do. You are appreciated more than you know. And to Rocky, whose unwavering support throughout the years leaves me forever grateful. You believed in me, even when I didn’t believe in myself. Thank you. iv ACKNOWLEDGEMENTS Dr. Drum – I didn’t think it could be done, but we did it! Thank you for lending your incredible knowledge to this thesis and for your unrelenting commitment to this program. Your dedication to your students, residents and the field of endodontics is truly amazing. Dr. Reader – I am so lucky to have had the opportunity to train under you. You bring excitement and energy to the program. Thank you for your dedication to educating the next generation of endodontists. I will never forget the lessons you taught me, in both endodontics and life. Dr. Nusstein – You are an incredible educator. I am so grateful I had the opportunity to work with you. Thank you for teaching me the value of thinking critically. I will never read the JOE the same again. Dr. Fowler – I am so glad that you have chosen to pursue education. It is the perfect fit for you! You are a wonderful teacher, and future students and residents will be lucky to have you. Dr. Beck – I’m sure the last thing you wanted to see at 6:30 a.m. each day was me in your office, but you always had a smile on your face. Thank you for taking the time and having the patience to walk me through the realm of statistics. Taryn, Ryan & Jared – From our first trip to Philadelphia, to our last trip to D.C., I’ve really enjoyed being your co-resident and friend. We’ve laughed together (mostly at each other), learned together and practiced endo together. There is no one else I would have rather gone through this residency with than you three! For your friendship and support, in and out of school, I thank you. v VITA April 10, 1987.……………………………………...Born: Royal Oak, MI May 2011……………………………………….......Bachelor of Science, Biology University of Detroit Mercy Detroit, MI Doctor of Dental Surgery, University of Detroit Mercy School of Dentistry Detroit, MI August 2014……………...…………………………Specialization in Endodontics Post-Doctoral Certificate, The Ohio State University College of Dentistry, Columbus, Ohio FIELD OF STUDY Major Field: Dentistry Specialization: Endodontics vi TABLE OF CONTENTS Page Abstract…………………………………………………………………………...………ii Dedication……………………………………………………………………………..….iv Acknowledgments………………………………………………………………….…….v Vita…………………………………………………………………………………....…..vi Table of Contents………………………………………………………………....….......vii List of Tables………………………………………………………………………...…...ix List of Figures……………………………………………………………….………...….xi Chapters: 1. Introduction………………………………………………………….…………….1 2. Materials and Methods…………………………………………….……………..28 3. Results……………………………………………………………….………..….37 4. Discussion…………………………………………………………….……..…...43 5. Summary and Conclusions………………………………………….……….......86 List of References………………..……………………………..…………..………...….88 Appendices A. Tables…………………………………………………...……………………96 B. Figures……………………………………………………...……………….115 vii C. Consent Form…………………………………………………...…………..119 D. Privacy Form………………………………………………………...…...…126 E. Corah’s Dental Anxiety Scale………………………………...……...….….131 F. Health History Questionairre ………………………………………………133 G. Initial Visual Analog Scale...……………………...…………………...…...136 H. Anesthetic Injection Visual Analog Scale………………………………….138 I. Emergency Treatment Visual Analog Scale…………………………….….140 J. Supplemental Injection Visual Analog Scale………………………………142 K. Post-supplemental Injection Visual Analog Scale………………….………144 viii LIST OF TABLES Table Page 1. Preliminary Data of Debridement and Non-Debridement Groups………..…......97 2. Pre-Operative Statistics by Jaw and Tooth Type.………..………........................98 3. Pre-Operative Statistics by Treatment Type.………………………………..…...99 4. Injection Pain………………………....…………………………………….…..100 5. Injection Pain by Stage Using Categorical Values of the VAS.…………....…..101 6. Emergency Treatment Pain…………..……………………………………..…..102 7. Emergency Treatment Pain by Stage Using Categorical Values of the VAS……………………………………………………………………....…….103 8. Escape Drug Utilization……………... ………………………………………...104 9. Non-Escape Group Post-Operative Pain by Day…………………..………..…105 10. Non-Escape Group Post-Operative Pain by Stage Using Categorical Values of the Visual Analog Scale ………………………………………………..……..……106 11. Escape Group Post-Operative Pain by Day ……………………………………107 12. Escape Group Post-Operative Pain by Stage Using Categorical Values of the Visual Analog Scale…………………....……………………………………….108 ix 13. Total Number of Pain Medication Tablets by Day ………...…………………..109 14. Number of Patients Utilizing No Medication by Day …….…….………...…..110 15. Total Number of Patients Utilizing an Escape Drug by Day ……………..……111 16. Escape Group Number of Narcotic Tablets Taken by Day…………………….112 17. Non-Escape Group Post-Operative Drug Use by Day……………………….…113 18. Escape Group Post-Operative Drug Use by Day……………………………….114 x LIST OF FIGURES Figure Page 1. Post-Operative Pain by Group and Day ………….………………………….....116 2. Medication Use by Group and Day………….....................................................117 3. Escape Drug Use……………………………………………………………..…118 xi CHAPTER 1 INTRODUCTION Symptomatic teeth with a pulpal diagnosis of necrosis are frequently treated in a specialty endodontic practice (1-4). Usually, accessing the tooth and performing canal debridement is completed at the initial emergency visit. However, many general dental practitioners do not access a tooth or perform initial canal debridement when the patient is symptomatic. Rather, they prescribe pain medications and antibiotics and then reappoint the patient when the symptoms have subsided. In addition, there are many patients without a general dentist or access to dental care that present to a hospital emergency room with symptomatic teeth. These patients presenting to the emergency room with severe odontogenic pain are also typically prescribed pain medication and antibiotics until they can be evaluated and treated by a dentist (5). According to the National Hospital Ambulatory Medical Care Survey, dental emergency room visits in the United States increased by 1 million from 2000 to 2010 (6). In an article published in the ADA News, a community dental health coordinator was interviewed and asked about dental emergency room visits. She stated that she sees patients daily who have waited too long for dental treatment. “Often, they’ve visited the emergency room and received antibiotics as a temporary treatment but haven’t followed up with a dentist to completely resolve their problem.” (6) In a study conducted by Shah et al., a retrospective analysis was conducted of patients admitted to the emergency room 1 with a diagnosis of periapical