Post-operative pain and discomfort are not uncommon following root canal treatment with a reported incidence of between 25-40%. A variety of drugs have been used for the management of post endodontic pain including non-narcotic analgesics comprising non-steroidal anti-inflammatory medicines (NSAIDs) and acetaminophen, opioids and steroids.
The aim of this trial was to assess the effect of a preoperative, single, oral dose of prednisolone on post-operative pain and postoperative analgesic intake in patients with symptomatic, irreversible pulpitis in mandibular molars.
Patients aged 18-35yrs with mandibular molars with symptomatic irreversible pulpitis, radiographically normal periapical area and no pain on biting or percussion were eligible for inclusion. Patients underwent single-visit root canal treatment (RoCT) under rubber dam to a standard protocol by trained and calibrated post-graduate students. Patients were randomised to receive 40 mg prednisolone or placebo 30 mins before local anaesthesia administration.
Patients received a pain diary and visual analogue scale (VAS) for three time-points. Patients were contacted to remind them to complete the VAS. All patients were provided with a placebo for ‘rescue analgesia’ post operatively If required the patient was instructed to contact the operator who would then prescribe an analgesic (Diclofenac Potassium 50 mg).
The primary outcome was the incidence of postoperative pain at the three time-points: 6, 12 and 24 h. The incidence of postoperative pain was measured as a binary outcome; ‘No pain’ if the patient scored ‘zero’ and ‘Pain’ if the patient scored otherwise on the visual analogue scale. Secondary outcomes included pain intensity and analgesic use.
- 400 patients were randomised (200 to prednisolone group and 200 to placebo)
- 2 patients in the prednisolone group were lost to follow up.
|Any Pain at||Prednisolone group||Placebo Group||Relative risk reduction (95%CI)|
|6 hrs||142||180||20.31%, (12.03% to 27.82%)|
|12 hrs||135||178||23.39% (14.75% to 31.16%)|
|24 hrs||112||159||28.85% (18.08% to 38.20%)|
- The prednisolone group had significantly lower pain intensity compared to the placebo group at 6, 12 and 24 h.
- The incidence of sham uptake was significantly less in the prednisolone group compared to the control group RRR= 54% (95% CI: 38%, 66%)
- The incidence of analgesic intake was significantly less in the prednisolone group compared to the control group RRR= 55% (95% CI: 3%, 79%).
- There were 12 endodontic file fractures in the prednisolone group and 16 in the control group.
- No adverse effects were reported
The authors concluded:-
Preoperative oral administration of a single dose of 40 mg prednisolone was beneficial for the control of postoperative pain up to 24 h after single-visit root canal treatment in patients with symptomatic irreversible pulpitis.
This large well-conducted single centre RCT demonstrates a reduction in pain with the use of prednisolone at 6, 12 and 24 hrs. Interestingly the primary outcome was no pain, so while 90% of the placebo group reported some pain at 6 hrs only 71% of patients in the prednisolone group reported some pain reducing to 79% and 56% respectively at 24hrs. The intensity of pain was also significantly lower in the prednisolone group at all three time points. An interesting aspect of this study is the decision to use a placebo as the first stage rescue medication with 22% in the prednisolone group and 48% in the placebo group taking using this analgesic placebo with 4.5 % of patients taking prednisolone and 10 % of those in the placebo group going on to use the diclofenac.
It is worth noting that earlier reviews (Dental Elf -7th Jun 2017) have demonstrated a significant effect for NSAIDs on post endodontic treatment with ibuprofen, flurbiprofen, and ibuprofen plus acetaminophen providing the greatest reductions in pain.
Elkhadem A, Ezzat K, Ramadan M, AbdelGhaffar S, Khamis D, Hassan A, Abdel-Mawgoud A, Mamdouh A, AbouZeid M, Amin S. The effect of preoperative oral administration of prednisolone on postoperative pain in patients with symptomatic irreversible pulpitis: a single-centre randomized controlled trial. Int Endod J. 2017 May 31. doi: 10.1111/iej.12795. [Epub ahead ofprint] PubMed PMID: 28560802.
Dental Elf – 7th Jun 2017