Post-op pain: Of hoofbeats and horses

June 1, 2005
Your patient calls with postoperative pain and you are confident that the procedure has been performed to the highest standard possible.

Your patient calls with postoperative pain and you are confident that the procedure has been performed to the highest standard possible. What do you do? First, believe the patient. Lawsuits and state board complaints arise when a patient has informed his or her dentist about being in pain but feels the comments go ignored or unheard. It is best to physically see the patient, evaluate the clinical situation, and not have a staff person try to manage the patient’s pain on the phone. While it is not possible in a single column to exhaustively deal with all postoperative clinical situations, let me address several common scenarios and solutions:

1)Besides percussion, palpation, mobility, probings, and possible swelling, the occlusion should always be checked first upon re-evaluation. A temporary filling or buildup that is even slightly high can place a tooth in hyperocclusion and cause significant pain. This is especially true of biting. Often, simple occlusal adjustment is all that is needed.

2)Within normal limits, patients can certainly have mild soreness after treatment. But, in the vast majority of cases, this should be more from the injections and being open for extended periods than from apical postoperative inflammation. If different patients are calling back frequently with postoperative pain, something is awry in the clinician’s treatment regimen. For example, hypochlorite might extrude from irrigation procedures. Severe postoperative pain after well-done endodontic procedures is - and should be - very uncommon, especially if the best endodontic treatment protocols are followed. When you hear hoofbeats, think of horses. Occasionally, the sound might be from a zebra, but not often. In endodontic terms, minimal postoperative pain is consistent with excellent clinical results (the horses’ hoofbeats), and vice versa.

3)If the patient has fluctuant swelling where he or she did not before, the most efficient means to manage the situation in order to produce the most predictable results is via incision and drainage. To prescribe antibiotics, and hope that the patient will improve, is not predictable. Sedation is optimal for incision and drainage as using only local anesthetic is rarely pain-free.

4)If the patient is in worse pain than before the root canal (assuming pain was present prior to the procedure), it is possible that the inflammation will be transitory. Prescribing pain medications, anti-inflammatory drugs, and/or steroids, as indicated, might be appropriate. But if the patient is not improving, getting worse, and/or is becoming swollen during a period of hours to days (especially in the presence of the medications), the patient should be re-evaluated with an eye toward the most appropriate intervention for the clinical case. Intervention might include trephination, apical surgery, or retreatment. Solely medicating such a patient, hoping that he or she will improve - especially when the pain is worsening and/or severe and swelling may be beginning - simply is not predictable. While there may be exceptions, in this scenario, some form of intervention is indicated.

5)A coronal seal is essential, even if the patient has some level of postoperative pain. Just because the patient has some tenderness to chewing, or other such complaints, it is no reason to delay the coronal seal, especially if the endodontics is of a high standard. Many patients have waited six months or more with some smoldering complaint about a root canal-treated tooth, and neglected the coronal seal. Two things are wrong in this scenario. First, temporary fillings are not meant to last more than a few weeks, probably six at the most. Relying on a temporary filling for many months puts the tooth at risk to bacterial invasion. Second, if the tooth is still sensitive after any given length of time, it is likely that there is uncleaned and unfilled canal space within the tooth. Surgery or retreatment is indicated. MB2 canals in the MB roots of upper molars that are untreated often give such lingering symptoms, and/or there is a vertical fracture of one of the roots, depending on the tooth. If a permanent buildup is placed in a tooth with mild lingering symptoms, and the endodontics has been done to a high standard, the tooth can later be retreated as needed and/or surgery can be employed as clinically appropriate.

After using RealSeal (SybronEndo, Orange, Calif.), it is my empirical observation that the material - in combination with excellent cleaning and shaping procedures - causes less and certainly no more postoperative discomfort in its use. I welcome your questions and feedback.

Dr. Richard Mounce is in private endodontic practice in Portland, Ore. Dr. Mounce is the author of a comprehensive DVD on cleansing, shaping, and packing the root canal system for the general practitioner. The material is also available as audio CDs and as a Web cast pay-per-view. Dr. Mounce lectures worldwide and is a widely published author. For more information, contact Dr. Mounce via e-mail at comf[email protected], or visit his Web site at