Clinical Research
An Analysis of Current Analgesic Preferences for
Endodontic Pain Management
André K. Mickel, DDS, MSD, Andrew P. Wright, DDS, Sami Chogle, BDS, DDS, MSD,
Jefferson J. Jones, DDS, Igor Kantorovich, DDS, MSD, and Francis Curd, DDS
Abstract
A descriptive, cross sectional survey was developed to
determine the preferences of endodontists when pre-
scribing analgesics. Eleven clinical scenarios describing
common endodontic diagnoses or procedures with
specified severity of pain were provided. A survey was
sent to 310 AAE members and 63 responded, providing
a 20% response rate. Respondents were given various
choices for analgesic prescription including various dos-
ages of ibuprofen or acetaminophen (APAP), or com-
bination narcotic medications. Data were analyzed by
␹2 tests. Non-narcotics were preferred over narcotics
for all clinical situations. Significantly more respondents
selected ibuprofen 600 mg (4⫻ a day) regardless of the
severity of preoperative or postoperative pain (p ⬍
0.001). Educators and board-certified AAE members
were less likely than nonboard certified AAE members
to manage their patient’s perceived severe pain with
narcotic analgesics. (J Endod 2006;32:1146 –1154)
Key Words
Acetaminophen, analgesics, cross-sectional survey, di-
agnosis, emergency, flare-up, ibuprofen, narcotic med-
ications, postoperative pain, severity of pain
From the Case School of Dental Medicine, Graduate En-
dodontics, Cleveland, Ohio.
Address requests for reprints to Dr. André K. Mickel, Case
School of Dental Medicine, Graduate Endodontics, 2123 Abington
Rd, Cleveland, OH 44106. E-mail address: axm69@cwru.edu.
0099-2399/$0 - see front matter
Copyright © 2006 by the American Association of
Endodontists.
doi:10.1016/j.joen.2006.07.015
1146 Mickel et al.
I t is well established that, in general, preoperative pain is the primary factor in deter-
mining the level of postoperative pain. One study reported that tooth pain is the most
common form of pain in the oral facial region (1). Another study demonstrated that
20% of patients have moderate to severe postendodontic pain. In their study, moderate
pain was defined as pain requiring medication and severe pain was pain not relieved by
medication and required palliative treatment. The results did not show a difference in
pain after endodontic therapy of nonvital teeth compared with vital teeth nor of nonvital
with or without periapical radiolucencies (2). However, few research studies have been
conducted on current use of analgesic preferences of endodontists in helping manage
tooth-related pain.
From two separate studies, a flexible analgesic prescription strategy promotes effective
management of severe pain (3, 4). In addition, NSAIDs, acetaminophen, and opioids are
active analgesics and can have additive effects when combined. Because opioids and
NSAIDs produce analgesia by different mechanisms, the simple additive effect of ad-
ministering an opioid in combination with an NSAID is often substantially greater than
the analgesia achieved by doubling the dose of either drug administered alone (5).
Dental pain is a complex process that is partly comprised of biological, biochem-
ical, environmental, and psychogenic factors. Many factors can influence clinicians’
decisions to prescribe analgesics in helping combat their patients’ postoperative pain.
Currently, there is a gap in the endodontic literature of how a particular endodontic
diagnosis, the surgical and nonsurgical endodontic procedure involved, and the perceived
level of patient pain will affect the choice of analgesic or combination of analgesics (non-
narcotic and narcotic) prescribed? The aim of this study is to investigate and assess this gap
in knowledge. We hypothesized that ibuprofen would be used most often regardless of the
endodontic diagnosis, procedure rendered, or the severity of perceived pain present.
Materials and Methods
The study population consisted of 310 randomly selected members of the Amer-
ican Association of Endodontists (AAE). Data were collected by a self-administered
electronic mail questionnaire. The survey consisted of 26 questions that were precoded.
Surveys were electronically mailed separately to each selected AAE member. The ques-
tionnaire represented a wide geographic region in the United States as well as interna-
tionally (Districts I–VII as listed in the AAE Directory). Eleven clinical scenarios were
developed describing common endodontic diagnoses or procedures and specified
severity of pain. For each scenario, respondents were given choices for analgesic pre-
scription: no medication, various dosages of ibuprofen or acetaminophen, and narcotic
medications given in combination with acetaminophen or ibuprofen. Additionally, the
respondent could indicate an alternative analgesic preference, as well as a “choose not
to answer box.” The questions attempted to obtain data on prescription practices,
location of practice, board certification, type of endodontist (clinician, educator, or
resident) as well as number of years in practice.
Results
From the 310 surveyed AAE members, 63 responded, giving a 20% response rate.
In the present study, it was found to be statistically significant that 600 mg ibuprofen
given four times per day was the most preferred analgesic prescribed for patients
regardless of their perceived level of pain, endodontic diagnosis, or treatment rendered
(Table 1). Although not statistically significant, the prescription of narcotics increased
JOE — Volume 32, Number 12, December 2006
 Clinical Research
TABLE 1. Questionnaire: For the following questions, please indicate your choice of analgesic that you would recommend/prescribe for your patient post-
operatively (Assume: 1) The patient is healthy with no allergies and no medical concerns 2) Adequate cleaning and shaping was
performed)
1. Patient A presents with severe pain and the diagnosis was Frequency Percent
Irreversible Pulpitis with Acute Periradicular Periodontitis: No Answer 3 4.8
No medication 4 6.3
400 mg Ibuprofen 1 1.6
600 mg Ibuprofen 20 31.7
800 mg Ibuprofen 11 17.5
Vicodin®* 4 6.3
Vicoprofen®† 3 4.8
Other 5 7.9
Ibuprofen⫹Vicodin® 8 12.7
Ibuprofen⫹APAP 3 4.8
Lortab®‡⫹Ibuprofen 1 1.6
Total 63 100.0
2. Patient B presents with severe pain and the diagnosis was Frequency Percent
Necrotic Pulp with Acute Periradicular Abscess: No Answer 3 4.8
No Medication 4 6.3
600 mg Ibuprofen 14 22.2
800 mg Ibuprofen 12 19.0
Vicodin® 7 11.1
Vicoprofen® 3 4.8
Other 3. 4.8
Vicodin®⫹Ibuprofen 11 17.5
Ibuprofen⫹APAP 4 6.3
Lorcet®§ 1 1.6
Lortab®⫹Ibuprofen 1 1.6
Total 63 100.0
3. Patient C presents with moderate pain and the diagnosis Frequency Percent
was Irreversible Pulpitis with a Normal Periradicular Area: No Answer 6 9.5
No Medication 5 7.9
400 mg Ibuprofen 5 7.9
600 mg Ibuprofen 21 33.3
800 mg Ibuprofen 8 12.7
650 mg APAP 1 1.6
1000 mg APAP 1 1.6
Vicodin® 6 9.5
Other 1 1.6
Ibuprofen⫹Vicodin® 4 6.3
Ibuprofen⫹APAP 4 6.3
Lortab®⫹Ibuprofen 1 1.6
Total 63 100.0
4. Patient D presents with severe pain, the diagnosis was Frequency Percent
Irreversible Pulpitis with an Acute Periradicular No Answer 5 7.9
Periodontitis, but the patient reschedules and asks you No Medication 3 4.8
about what to take for pain (no treatment was 400 mg Ibuprofen 1 1.6
performed): 600 mg Ibuprofen 21 33.3
800 mg Ibuprofen 11 17.5
Vicodin® 4 6.3
Vicoprofen® 2 3.2
Other 5 7.9
Ibuprofen⫹Vicodin® 7 11.1
Ibuprofen⫹APAP 2 3.2
Lorcet® 1 1.6
Lortab®⫹Ibuprofen 1 1.6
Total 63 100.0
5. What would you recommend to your patients Frequency Percent
postoperatively if Ca(OH)2 was placed to the working No Answer 9 14.3
length in a vital tooth? No Medication 13 20.6
400 mg Ibuprofen 4 6.3
600 mg Ibuprofen 21 33.3
800 mg Ibuprofen 11 17.5
Vicodin® 3 4.8
Vicoprofen® 1 1.6
Ibuprofen⫹APAP 1 1.6
Total 63 100.0
6. What do you typically recommend to your patients post- Frequency Percent
operatively if Ca(OH)2 was placed to the working length No Answer 9 14.3
in a necrotic tooth? No Medication 16 25.4
400 mg Ibuprofen 3 4.8

JOE — Volume 32, Number 12, December 2006 Analgesic Preferences for Endodontic Pain Management 1147
Clinical Research
TABLE 1. (Continued)
600 mg Ibuprofen 20 31.7
800 mg Ibuprofen 10 15.9
Vicodin® 3 4.8
Ibuprofen⫹Vicodin® 1 1.6
Lortab®⫹Ibuprofen 1 1.6
Total 63 100.0
7. What do you usually have your patients take post- Frequency Percent
operatively for Non-Surgical Retreatment therapy? No Answer 8 12.7
No Medication 12 19.0
400 mg Ibuprofen 6 9.5
600 mg Ibuprofen 19 30.2
800 mg Ibuprofen 9 14.3
Vicodin® 3 4.8
Other 3 4.8
Ibuprofen⫹Vicodin® 2 3.2
Lortab®⫹Ibuprofen 1 1.6
Total 63 100.0
8. What do you usually recommend after Surgical Root Canal Frequency Percent
Therapy Apicoectomy, Retrograde Filling) for your No Answer 6 9.5
patient? No Medication 1 1.6
400 mg Ibuprofen 4 6.3
600 mg Ibuprofen 15 23.8
800 mg Ibuprofen 10 15.9
Vicodin® 10 15.9
Vicoprofen® 1 1.6
Other 3 4.8
Ibuprofen⫹Vicodin® 9 14.3
Ibuprofen⫹APAP 1 1.6
Lorcet® 1 1.6
Lortab®⫹Ibuprofen 2 3.2
Total 63 100.0
9. What do you usually have your patients take post- Frequency Percent
operatively for a Combined Retreatment and Finalization No Answer 8 12.7
Procedure completed in 1 visit? (Apicoectomy, Retrograde No Medication 3 4.8
Filling after conventional RETX). 400 mg Ibuprofen 1 1.6
600 mg Ibuprofen 15 23.8
800 mg Ibuprofen 9 14.3
Vicodin® 10 15.9
Vicoprofen® 2 3.2
Other 5 7.9
Ibuprofen⫹Vicodin® 7 11.1
Ibuprofen⫹APAP 1 1.6
Lortab®⫹Ibuprofen 2 3.2
Total 63 100.0
10. What would you suggest that your patient take post- Frequency Percent
operatively after a diagnosis of Irreversible Pulpitis with No Answer 7 11.1
Acute Periradicular Periodontitis is made, a pulpectomy is No Medication 4 6.3
provided, and the patient experienced pain during the 400 mg Ibuprofen 2 3.2
procedure despite multiple techniques of local anesthesia 600 mg Ibuprofen 15 23.8
administration? 800 mg Ibuprofen 8 12.7
1,000 mg APAP 1 1.6
Vicodin® 10 15.9
Vicoprofen® 5 7.9
Other 1 1.6
Ibuprofen⫹Vicodin® 5 7.9
Ibuprofen⫹APAP 3 4.8
Lortab®⫹Ibuprofen 2 3.2
Total 63 100.0
11. If a patient you treated calls your office 1 week after Frequency Percent
treatment, describing symptoms consistent of a flare-up No Answer 3 4.8
postoperatively, what would you recommend/prescribe? No Medication 3 4.8
400 mg Ibuprofen 3 4.8
600 mg Ibuprofen 12 19.0
800 mg Ibuprofen 8 12.7
Vicodin® 10 15.9
Vicoprofen® 4 6.3
Other 10 15.9
Combo Ibuprofen and Vicodin® 6 9.5
Combo Ibuprofen and APAP 2 3.2
Combo Lortab® and Ibuprofen 2 3.2
Total 63 100.0

1148 Mickel et al. JOE — Volume 32, Number 12, December 2006
 Clinical Research
TABLE 1. (Continued)
12. What is your choice of a combination narcotic Frequency Percent
medication that you would use to help your patients No Answer 8 12.7
manage their severe postoperative endodontic pain? No Narcotics are Prescribed 5 7.9
Hydrocodone and Acetaminophen 31 49.2
Hydrocodone and Aspirin 1 1.6
Propoxyphene and Acetaminophen 1 1.6
Codeine and Acetaminophen 3 4.8
Oxycodone and Acetaminophen 4 6.3
Oxycodone and Aspirin 2 3.2
Other 2 3.2
Narcotic and Ibuprofen 6 9.5
Total 63 100.0
13. Approximately how often do you prescribe narcotic Frequency Percent
medications for your patients per week? No Answer 9 14.3
0–2 33 52.4
3–4 7 11.1
5–7 3 4.8
More than 7 10 15.9
Other 1 1.6
Total 63 100.0
14. How many times do you prescribe narcotic medications Frequency Percent
for your patients per month? No Answer 8 12.7
0–4 21 33.3
5–8 13 20.6
9–12 5 7.9
More than 12 16 25.4
Total 63 100.0
15. How long do you typically recommend your patients Frequency Percent
take a non-narcotic pain medication postoperatively No Answer 9 14.3
after non-surgical endodontic therapy for a symptomatic 1–2 days 19 30.2
tooth? 3–4 days 29 46.0
5–7 days 2 3.2
8–10 days 1 1.6
Other 1 1.6
As Needed 2 3.2
Total 63 100.0
16. How long do you typically recommend your patients Frequency Percent
take a non-narcotic pain medication postoperatively No Answer 9 14.3
after surgical endodontic therapy? 1–2 days 18 28.6
3–4 days 24 38.1
5–7 days 9 14.3
As Needed 3 4.8
Total 63 100.0
17. How long do you typically recommend your patients Frequency Percent
take a narcotic pain medication postoperatively after No Answer 12 19.0
non-surgical endodontic therapy for a symptomatic 1–2 days 29 46.0
tooth? 3–4 days 10 15.9
5–7 days 1 1.6
Other 3 4.8
As Needed 8 12.7
Total 63 100.0
18. How long do you typically recommend your patients Frequency Percent
take a narcotic pain medication postoperatively after No Answer 15 23.8
surgical endodontic therapy? 1–2 days 24 38.1
3–4 days 8 12.7
5–7 days 1 1.6
Other 6 9.5
As Needed 9 14.3
Total 63 100.0
19. How many times a day do you have your patients take a Frequency Percent
non-narcotic pain medication for postoperative pain No Answer 9 14.3
control? 1⫻/day 1 1.6
2⫻/day 1 1.6
3⫻/day 12 19.0
4⫻/day 36 57.1
Other 2 3.2
As Needed 2 3.2
Total 63 100.0

JOE — Volume 32, Number 12, December 2006 Analgesic Preferences for Endodontic Pain Management 1149
Clinical Research
TABLE 1. (Continued)
20. How many times a day do you recommend your patients Frequency Percent
take a narcotic pain medication for postoperative pain No Answer 15 23.8
control? 1⫻/day 1 1.6
2⫻/day 2 3.2
3⫻/day 8 12.7
4⫻/day 28 44.4
Other 3 4.8
As Needed 6 9.5
Total 63 100.0
21. Do you combine non-narcotic pain medications for post- Frequency Percent
operative pain control? No Answer 6 9.5
Yes 36 57.1
No 19 30.2
Depends 2 3.2
Total 63 100.0
22. If you answered “Yes” or “Depends” to question 21, Frequency Percent
please indicate what non-narcotic pain medications that No Answer 28 44.4
you have your patients take: Ibuprofen 10 15.9
Acetaminophen 1 1.6
Ibuprofen and Acetaminophen 22 34.9
Ketoprofen 1 1.6
Toradol®储 1 1.6
Total 63 100.0
23. Are you currently Board Certified by the American Board Frequency Percent
of Endodontists? Board Certified 11 17.5%
Non-Board Certified 52 82.5%
24. When did you graduate from your endodontic training Frequency Percent
program? Prior to 1980 5 7.9%
Between 1981–1990 13 20.6%
Between 1991–2000 29 46.0%
Between 2001–2006 16 25.4%
25. Please select one of the following that best describes Frequency Percent
your practice background (educator, resident, clinician): Endodontic Resident 7 11.1%
Educator 8 12.7%
Clinician 48 88.9%
26. Please select where you currently practice (Districts I–VII): Frequency Percent
District I 7 11.1%
District II 0 0.0%
District III 9 14.3%
District IV 10 15.9%
District V 27 42.9%
District VI 8 12.7%
District VII 2 3.2%
*Vicodin® is a registered trademark of Knoll Pharmaceutical.
†Vicoprofen®, a registered trademark of Abbott Laboratories.
‡Lortab® is a registered trademark of Whitby.
§Lorcet® is a registered trademark of Forest Pharmaceuticals.
储Toradol is a registered trademark of Roche Laboratories.

in the following conditions: (28%) postsurgical pain, (31%) postoper-
ative flare-up, or (34%) severe pain associated with a necrotic pulp and
acute periradicular abscess. As seen in Table 1, approximately 30 to
33% of respondents chose to prescribe 600 mg ibuprofen after placing
calcium hydroxide versus 20 to 26% choosing no medication. In addi-
tion, although not listed as analgesic choices, respondents listed
antibiotics to help alleviate endodontic pain including an endodontic
diagnosis of irreversible pulpitis with acute periradicular periodontitis.
As seen in Table 2, the data was determined to be statistically
significant (p ⫽ 0.037) that clinicians, educators, and endodontic res-
idents chose either no medication, ibuprofen, a narcotic, or a combi-
nation narcotic/non-narcotic analgesic medication when managing pa-
tients
with severe pain. An apparent distribution difference was noted. Ap-
proximately 33% of educators chose no medication where as 2% of
clinicians and 0% of residents chose no medication. In addition, 11% of
educators chose a combination analgesic whereas 33% of clinicians
and 17% of residents chose a combination analgesic. Approximately
45% of educators, 53% of clinicians, and 67% of residents chose ibu-
profen. Furthermore, 11% of educators, 11% of clinicians, and 17% of
residents chose narcotics (Table 2). As depicted in Tables 3–5, it was
found to be statistically significant that respondents who were either
board-certified or non-board-certified chose no medication, ibuprofen,
a narcotic analgesic, or a combination non-narcotic/narcotic analgesic
as their preferred pain medication for question 1 (p ⫽ 0.019), 8 (p ⫽
0.038), and 11 (p ⫽ 0.036). Another apparent distribution difference
was noted in terms of board certification versus managing severe pain.
As seen in Table 3, no medication was chosen by 2% of non-board-
certified respondents and 25% of board-certified respondents. Ibupro-
fen was chosen by 52% of non-board-certified respondents and 59% of

1150 Mickel et al. JOE — Volume 32, Number 12, December 2006
 Clinical Research
TABLE 2. Response distribution and statistics for question 1* in relation to practice background (question 25†)
Practice Background
Med Choice Endo Resident Educator Clinician
Count % Count % Count %
No med 0 0.0% 3 5.0% 1 1.7%
Ibuprofen 4 6.7% 4 6.7% 24 40.0%
Narcotic 1 1.7% 1 1.7% 5 8.3%
Combo 1 1.7% 1 1.7% 15 25.0%
Total 6 10.0% 9 15.0% 45 75.0%
*Patient A presents with severe pain and the diagnosis was Irreversible Pulpitis with Acute Periradicular Periodontitis.
†Please select one of the following that best describes your practice background (educator, resident, clinician).
␹2 ⫽ 13.437; p ⬍ 0.05.

board-certified respondents. Narcotics were chosen by 13% of non- mentioned that endodontic pain is best managed by eliminating the
board-certified respondents and 10% of board-certified respondents. source as completely as possible along with judicious use of local an-
Combination analgesics were chosen by 33% of non-board-certified esthetics, nonopioid and opioid analgesics.
respondents and 8.5% of board-certified respondents (Table 3). Ibuprofen blocks both the cyclo-oxygenase-1 (COX-1) and cyclo-
As seen in Table 4, no medication was chosen by 0% of non-board- oxygenase-2 (COX-2) enzymes, but it is safe and cost-effective with
certified respondents and 10% of board-certified respondents, respec- highly effective analgesic and anti-inflammatory action for posten-
tively. Ibuprofen was chosen by 52% of non-board-certified respon- dodontic pain (3). Holt et al. (8) found no significant differences in
dents and by 75% of board-certified respondents. Narcotics were COX-1 and COX-2 levels among Celebrex, Vioxx, and Advil, but that
chosen by 13% of non-board-certified respondents and by 9% of board- Vioxx and Advil significantly reduced COX-2 expression levels compared
certified respondents. Combination analgesics were chosen by 33% of to inflamed pulps.
non-board-certified respondents and by 0% of board-certified respon- Gallatin et al. (9) evaluated pain reduction using an intraosseous
dents (Table 4). injection of slow-releasing methylprednisolone in teeth with irrevers-
As seen in Table 5, no medication was chosen by 2.1% of non- ible pulpitis. Over the seven-day observation period, the subjects who
board-certified respondents and by 16.5% of board-certified respon- received the intraosseous injection of Depo-Medrol (Pharmacia &
dents. Ibuprofen was chosen by 35% of non-board-certified respon- Upjohn Company, New York, NY) reported significantly less pain and
dents and by 50% of board-certified respondents. Narcotics were percussion pain while taking fewer pain medications. Clinically, the
chosen by 21% of non-board-certified respondents and by 34% of intraosseous injection of Depo-Medrol could be used to temporarily
board-certified respondents. Combination analgesics were chosen by alleviate the symptoms of irreversible pulpitis until definitive treatment
21% of non-board-certified respondents and by 0% of board-certified can be rendered.
respondents (Table 5). The results from this present study are consistent with the findings
of Krasner and Jackson (10) who noted from their study that although
Discussion pulpectomy eliminates endodontic pain, postoperative pain and dis-
It was noted from this study that respondents were more likely to comfort are fairly common side effects of endodontic treatment, a prob-
prescribe analgesics when surgical therapy was provided, during retreat- lem for 25 to 40% of all endodontic patients. Hasselgren and Reit (11)
ment therapy with the placement of calcium hydroxide as well as for flare- concluded that removal of caries, pulpotomy, and sealing of the cavity
ups. The prescription of narcotics increased in the following conditions: apparently was a reliable means to relieve pain. In a survey by Gatewood
postsurgical pain (28%), postoperative flare-up (31%), or severe pain as- et al. (12), a majority of American Board of Endodontist diplomates
sociated with a necrotic pulp and acute periradicular abscess (34%). completely instrumented the canals regardless of the clinical diagnosis.
Sutherland and Matthews’ (6) meta-analysis on the effectiveness of Pain after endodontic procedures is another reason for emergency
interventions used in the emergency management of acute apical treatment.
periodontitis showed that preemptive NSAIDs in conjunction with As noted from the results of this study, respondents’ felt that plac-
pulpectomy, provided a significant benefit. In the article by Haas (7) he ing calcium hydroxide as an intra-canal medication can cause perceived
TABLE 4. Response distribution and statistics for question 8* in relation to
TABLE 3. Response distribution and statistics for question 1* in relation to board certification
board certification
Board Certification
Board Certification
Med Choice No Yes
Med Choice No Yes
Count % Count %
Count % Count % No med 0 0.0% 1 1.8%
No med 1 1.7% 3 5.0% Ibuprofen 20 31.5% 9 15.8%
Ibuprofen 25 41.7% 7 11.7% Narcotic 11 19.3% 1 1.8%
Narcotic 6 10.0% 1 1.7% Combo 12 21.1% 0 0.0%
Combo 16 26.7% 1 1.7% Other 2 3.5% 1 1.8%
Total 48 80.0% 12 20.0% Total 45 78.9% 12 21.1%
*Patient A presents with severe pain and the diagnosis was Irreversible Pulpitis with Acute Periradicular *What do you usually recommend after Surgical Root Canal Therapy Apicoectomy, Retrograde Filling
Periodontitis. for your patient?
␹2 ⫽ 9.893; p ⬍ 0.05. ␹2 ⫽ 10.129; p ⬍ 0.05.

JOE — Volume 32, Number 12, December 2006 Analgesic Preferences for Endodontic Pain Management 1151
Clinical Research
TABLE 5. Response distribution and statistics for question 11* in relation to
board certification
Board Certification
Med Choice No Yes
Count % Count % odontitis, and necrotic pulp with acute periradicular abscess were
No med 1 1.7% 2 3.3%
Ibuprofen 17 28.3% 6 10.0%
Narcotic 10 16.7% 4 6.7%
Combo 10 16.7% 0 0.0%
Other 10 16.7% 0 0.0%
Total 48 80.0% 12 20.0%
*If a patient you treated calls your office 1 week after treatment, describing symptoms consistent of a
flare-up postoperatively, what would you recommend/prescribe?
␹2 ⫽ 10.259; p ⬍ 0.05.
postoperative discomfort for the patient. In the article by Rogers et al.
(13), they compared the pain-reducing efficacy of dexamethasone and
ketorolac tromethamine when used as an intracanal medication, with
oral ibuprofen and a placebo. An additional objective was to establish if
any relationship exists between the incidence of severity of pretreatment
pain and the incidence and severity of postinstrumentation pain. At the
12-hour period, both dexamethasone and ketorolac were statistically
significant in providing better pain relief in comparison to a placebo. In
addition, no significant differences were demonstrated between ibupro-
fen and either dexamethasone or ketorolac.
In terms of postoperative surgical pain, it was found in this study
that a majority of respondents chose 600 mg ibuprofen and occasionally
hydrocodone to alleviate pain. Several respondents wrote in their
responses that their patients respond very well and have minimal post-
operative pain. There could be several reasons for this result: manipu-
lation of the surgical flap, duration of the surgical procedure, as well as
the surgical technique employed. In the study conducted by Chong and
Pitt Ford (14), they evaluated the pain experience following root-end
resection and filling with mineral trioxide aggregate or intermediate
restorative material (IRM). Thirty-seven percent of patients did not take
any analgesics following treatment. In order of popularity, the analge-
sics taken were ibuprofen, acetaminophen, and acetaminophen plus
codeine. There was no significant difference in the pain experienced by
both treatment groups. The postoperative pain was of a relatively short
duration, at its maximum intensity early in the postoperative period but
progressively decreased with time.
Conversely to the findings of Chong and Pitt Ford, in the study
conducted by Kvist and Reit, (15) they noted that significantly more
patients reported discomfort after surgical retreatment than after
nonsurgical procedures. High pain scores were most frequent on
the operative days whereas swelling reached its maximum on the
first postoperative day followed by progressive decrease both in
frequency and magnitude. Postoperative symptoms associated with
nonsurgical retreatment were less frequent but reached high VAS
values in single cases. Analgesics were significantly more often con-
sumed after periapical surgery than after nonsurgical procedures.
Conclusively, surgical retreatment resulted in more discomfort for
the patient.
In the study by Tsesis et al. (16), they compared patient expe-
rience of quality of life after surgical endodontic treatment using two
different techniques: a technique that included the use of a dental
operating microscope, root resection with minimal bevel and ret-
rograde preparation with ultrasonic tips, and a traditional tech-
nique that included root resection with a 45 degree bevel and ret-
rograde preparation by bur performed without magnification.
Patients in both groups reported a high incidence of symptoms. The
1152 Mickel et al.
technique using the operating microscope provided significantly
less postoperative pain, but more difficulties in mouth opening,
mastication, and the ability to speak immediately postoperatively.
Results from this study indicated that symptomatic patients with
the diagnoses of irreversible pulpitis with acute periradicular peri-
the most common for respondents to choose analgesics to relieve
their patients’ pain. In the study by Nusstein and Beck (17), they
compared differences in preoperative pain and medication use in
patients with moderate to severe pain who sought emergency end-
odontic care for teeth with irreversible pulpitis and for symptomatic
teeth with necrotic pulps. Non-narcotic analgesics were reported to
significantly reduce pain more often in patients with symptomatic
teeth with necrotic pulps.
Similarly, Houck’s group (18) found the majority of patients
with symptomatic necrotic teeth had significant postoperative pain
and required analgesics to manage this pain. In addition, our find-
ing corresponded to the study by Gopikrishna and Parameswaran (19)
who found that nine of seventeen teeth diagnosed with acute apical
periodontitis required additional medication to reduce postendodontic
pain. This finding was in concurrence with the study by Menke et al.
(20).
Although combining narcotic analgesics with non-narcotic an-
ti-inflammatory analgesics is beneficial in alleviating postoperative
pain, Litkowski et al. (21) found that rates of nausea and vomiting
were significantly lower with oxycodone-5 mg/ibuprofen-400 mg
compared with oxycodone-5 mg/acetaminophen-325 mg but not
with hydrocodone-7.5 mg/acetaminophen-500 mg. A majority of the
respondents in our study chose hydrocodone-5 mg/acetaminophen-
500 mg as their combination narcotic of choice.
In the present study, antibiotics (12%) were prescribed in
cases of severe pain or flare-ups. Some of these endodontic diag-
nose included irreversible pulpitis with an acute periradicular pe-
riodontitis. From the Cochrane Systematic Review by Keenan et al.
(22), they provided evidence that there is no significant difference
in pain relief for patients with untreated irreversible pulpitis who
received antibiotics versus those who did not. In the study by Nagle
et al. (23), they determined the effect of penicillin on pain in un-
treated teeth diagnosed with irreversible pulpitis. They concluded
that the administration of penicillin did not significantly reduce
pain, percussion pain, or the number of analgesic medications
taken by patients with untreated irreversible pulpitis. The majority
of patients with untreated irreversible pulpitis had significant pain
and required analgesics to manage this pain.
Furthermore, in the study by Henry et al. (24), they determined
the effect of penicillin on postoperative pain and swelling in symp-
tomatic necrotic teeth. The administration of penicillin postopera-
tively did not significantly reduce pain, percussion pain, swelling, or
the number of analgesic medications taken for symptomatic ne-
crotic teeth with periapical radiolucencies. The use of ibuprofen
and acetaminophen with codeine followed the pain ratings with the
highest usage initially and through day 3 followed by a decrease over
the 7 days. However, greater than 20% of the patients continued to
require analgesic medications through day 7.
In terms of preventing flare-ups, Pickenpaugh’s group (25)
determined the effect of prophylactic amoxicillin on the occurrence
of endodontic flare-up on asymptomatic, necrotic teeth. Prophylac-
tic amoxicillin did not significantly influence the endodontic flare-
up.
Although not evaluated in this present study, it was noted that
gender may have a contributing factor in the respondents’ perceived
level of patient postendodontic pain. In the study by Nusstein and Beck
JOE — Volume 32, Number 12, December 2006

(17), they noted that more women than men with irreversible pulpitis
would take an analgesic.
In the present study, there was an apparent distribution differ-
ence in the percentage of non-board and board-certified respon-
dents choosing no medication, ibuprofen, narcotic, or combination
analgesics for patients with severe pain and having an endodontic
diagnosis of irreversible pulpitis with acute periradicular periodon-
titis. Non-board-certified respondents (2%) were less likely to
choose no medication than board-certified respondents (25%).
One possible explanation is that board-certified members may be
more confident with their endodontic instrumentation to alleviate
their patients’ pain. Ibuprofen and narcotics were more equally
distributed, chosen approximately 50% and 10% of both groups,
respectively. Combination analgesics represented another apparent
distribution difference between board-certified and non-board-cer-
tified respondents. A higher percentage of non-board-certified re-
spondents in comparison to board-certified respondents chose
combination narcotics. These results may be because of non-board-
certified respondents relying more on analgesics to manage their
patient’s pain than board-certified respondents who rely more on
technique and non-narcotic analgesics. The apparent distribution
difference was also seen for questions 8 and 11. More board-certi-
fied respondents were consistently more likely to choose no medi-
cation or ibuprofen than non-board-certified respondents. An ad-
ditional factor that may have contributed to this distribution
difference could be the moderately low number of respondents in
this study.
Practice background was significant for analgesic preferences
relating to severe pain with an endodontic diagnosis of irreversible
pulpitis with acute periradicular periodontitis. The results from this
present study indicated that educators were more likely to choose
no medication after endodontic treatment to manage this painful
clinical scenario, whereas clinicians and residents were much more
likely to prescribe ibuprofen, combination analgesics, or narcotics
in addition to instrumentation. One factor that may have contributed
to this discrepancy could be a difference in the volume of patients
treated by educators versus clinicians on a daily basis.
As seen in the present study, there was a discrepancy of re-
spondents choosing to prescribe analgesics after calcium hydroxide
placement in either vital or nonvital teeth. Several reasons indicating
that calcium hydroxide may contribute to postoperative pain are:
coagulation necrosis (26), tissue dissolution (27), cytotoxicity
(28), and bone necrosis (29). Although these studies imply possible
pain associated with calcium hydroxide placement, calcium hydrox-
ide decreases production of arachidonic acid from membrane
phospholipids, thus decreasing levels of prostaglandin E2 and de-
creasing pain (30). In addition, Walton et al. (31) noted that no
significant difference in pain was found in teeth having necrotic
pulps and periradicular pathosis with or without symptoms treated
with calcium hydroxide or a dry cotton pellet. In addition, Yoldas et al.
(32) found that flare-ups and postoperative pain was lower in symptomatic
teeth treated in two appointments with calcium hydroxide in comparison to
those treated in one appointment. Future studies may look at how the sec-
ond appointment after calcium hydroxide placement will affect the respon-
dents’ choice of analgesics prescribed.
In the present study, it was found to be statistically significant
that 600 mg ibuprofen given four times per day was the preferred
analgesic prescribed for patients regardless of their perceived level
of pain, endodontic diagnosis, or treatment rendered. Narcotics
were prescribed in the following conditions: postsurgical pain
(28%), postoperative flare-up (31%), or severe pain associated
with a necrotic pulp and acute periradicular abscess (34%). Edu-
JOE — Volume 32, Number 12, December 2006
Clinical Research
cators were more likely to choose no medication than clinicians or
residents in managing patients with severe pain and an endodontic
diagnosis of irreversible pulpitis with acute periradicular periodon-
titis. Board-certified respondents were more likely to choose no
medication or ibuprofen to manage postsurgical endodontic pain or
flare-ups than non-board-certified respondents. There was a slight
discrepancy of when and why respondents prescribed analgesics for
retreatment procedures with the placement of calcium hydroxide as
well as the use of antibiotics to help alleviate endodontic pain. In this
study, most respondents used a consistent approach when prescrib-
ing analgesics to manage endodontic pain.
References
1. Lipton J, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of re-
ported of orofacial pain in the United States. J Am Dent Assoc 1993;124:115–21.
2. Georgopoulou M, Anastassiadis P, Sykaras S. Pain after chemomechanical prepara-
tion. Int Endod J 1996;19:309 –14.
3. Cooper S. The relative efficacy of Ibuprofen in dental pain. Compend Contin Educ
Dent 1986;7:578 – 88.
4. Breivik E, Barkvoll P, Skovlund E. Combining diclofenac with acetaminophen or
acetaminophen-codeine after oral surgery: a randomized, double-blind, single oral
dose study. Clin Pharmacol Ther 2000;66:625–35.
5. Wideman G, Keffer M, Morris E, Doyle R, Jiang J, Beaver W. Analgesic efficacy of a
combination of hydrocodone with Ibuprofen in postoperative pain. Clin Pharmacol
Ther 1999;65:66 –76.
6. Sutherland S, Matthews DC. Emergency management of acute apical periodontitis in the
permanent dentition: a systematic review of the literature. J Can Dent Assoc 2003;69:160.
7. Haas DA. Local and systemic therapeutics for the control of endodontic Pain. Alpha
Omegan 1997;90:73– 6.
8. Holt CI, Hutchins MO, Pileggi R. A real time quantitative PCR analysis and correlation
of COX-1 and COX-2 enzymes in inflamed dental pulps following administration of
three different NSAIDs. J Endod 2005;31:799 – 804.
9. Gallatin E, Reader A, Nist R, Beck M. Pain reduction in untreated irreversible pulpitis
using an intraosseous injection of Depo-Medrol®. J Endod 2000;26:633– 8.
10. Krasner P, Jackson E. Management of posttreatment endodontic pain with oral dexa-
methasone: a double-blind study. Oral Surg Oral Med Oral Pathol 1986;62:187–90.
11. Hasselgren G, Reit C. Emergency pulpotomy: pain relieving effect with and without the
use of sedative dressings. J Endod 1989;15:254 – 6.
12. Gatewood RS, Himel VT, Dorn SO. Treatment of the endodontic emergency: a decade
later. J Endod 1990;16:284 –91.
13. Rogers MJ, Johnson BR, Remeikis NA, BeGole EA. Comparison of effect of intracanal
use of ketorolac tromethamine and dexamethasone with oral Ibuprofen on post
treatment endodontic pain. J Endod 1999;25:381– 4.
14. Chong BS, Pitt Ford TR. Postoperative pain after root-end resection and filling. Oral
Surg Oral Medication Oral Pathol Oral Radiol Endod 2005;100:762– 6.
15. Kvist T, Reit C. Postoperative discomfort associated with surgical and nonsurgical
endodontic retreatment. Endod Dent Traumatol 2000;16:71– 4.
16. Tsesis I, Shoshani Y, Givol N, Yahalom R, Fuss Z, Taicher S. Comparison of quality of
life after surgical endodontic treatment using two techniques: a prospective study.
Oral Surg Oral Medication Oral Pathol Oral Radiol Endod 2005;99:367–71.
17. Nusstein JM, Beck M. Comparison of preoperative pain and medication use in emer-
gency patients presenting with irreversible pulpitis or teeth with necrotic pulps. Oral
Surg Oral Medication Oral Pathol Oral Radiol Endod 2003;96:207–14.
18. Houck V, Reader A, Beck M, Nist R, Weaver J. Effect of trephination on postoperative
pain and swelling in symptomatic necrotic teeth. Oral Surg Oral Medication Oral
Pathol Oral Radiol Endod 2000;90:507–13.
19. Gopikrishna V, Parameswaran A. Effectiveness of prophylactic use of rofecoxib in
comparison with Ibuprofen on postendodontic pain. J Endod 2003;29:62– 4.
20. Menke ER, Jackson CR, Bagby MD, Tracy TS. The effectiveness of prophylactic
etodolac on postendodontic pain. J Endod 2000;26:712–5.
21. Litkowski LJ, Christensen SE, Adamson DN, Van Dyke T, Han SH, Newman KB.
Analgesic efficacy and tolerability of oxycodone 5 mg/Ibuprofen 400 mg com-
pared with those of oxycodone 5 mg/acetaminophen 325 mg and hydrocodone 7.5
mg/acetaminophen 500 mg in patients with moderate to severe postoperative pain: a
randomized, double-blind, placebo-controlled, single-dose, parallel-group study in
a dental pain model. Clin Ther 2005;27:418 –29.
22. Keenan JV, Farman AG, Fedorowicz Z, Newton JT. A Cochrane systematic review finds
no evidence to support the use of antibiotics for pain relief in irreversible pulpitis. J
Endod 2006;32:87–92.
23. Nagle D, Reader A, Beck M, Weaver J. Effect of systemic penicillin on pain in untreated
irreversible pulpitis. Oral Surg Oral Medication Oral Pathol Oral Radiol Endod
2000;90:636 – 40.
Analgesic Preferences for Endodontic Pain Management 1153
Clinical Research
24. Henry M, Reader A, Beck M. Effect of penicillin on postoperative endodontic pain and
swelling in symptomatic necrotic teeth. J Endod 2001;27:117–23.
25. Pickenpaugh L, Reader A, Beck M, Meyers WJ, Peterson LJ. Effect of prophylactic Amoxi-
cillin on endodontic flare-up in asymptomatic, necrotic teeth. J Endod 2001;27:53– 6.
26. Schroder U, Granath LE. Early reaction of intact human teeth to calcium hydroxide
following experimental pulpotomy and its significance to the development of hard
tissue barrier. Odontol Revy 1971;22:379 –95.
27. Hasselgren G, Olsson B, Cvek M. Effects of calcium hydroxide and sodium hy-
pochlorite on the dissolution of necrotic porcine muscle tissue. J Endod
1988;14:125–7.
28. Alaçam T, Ömürlü H, Özkul A, Görgül G, Misirligil A. Cytotoxicity versus antibacterial
activity of some antiseptics in vitro. J Nihon Univ Sch Dent 1993;35:22–7.
1154 Mickel et al.
29. Himel VT, Brady J, Weir J. Evaluation of repair of mechanical perforations of the pulp
chamber floor using biodegradable tricalcium phosphate or calcium hydroxide. J
Endod 1985;11:161–5.
30. Segura JJ, Llamas R, Rubio-Manzanares AJ, Jimenez-Planas A, Guerrero JM, Calvo JR.
Calcium hydroxide inhibits substrate adherence capacity of macrophages. J Endod
1997;23:444 –7.
31. Walton RE, Holton IF Jr, Michelich R. Calcium hydroxide as an intracanal medication:
effect on posttreatment pain. J Endod 2003;29:627–9.
32. Yoldas O, Topuz A, Isci AS, Oztunc H. Postoperative pain after endodontic retreat-
ment: single- versus two-visit treatment. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2004;98:483–7.
JOE — Volume 32, Number 12, December 2006