Abstract
Background
Vital pulp therapy (VPT) is a contemporary approach for managing deep caries in permanent teeth. However, there is limited information about postoperative pain, especially in pediatric patients.
Objective
This comprehensive review examines English-language articles on postoperative pain after VPT, focusing on patient-reported discomfort from procedure completion to 7 days afterward. It aims to concisely summarize pain incidence, intensity, duration, analgesic usage, and associated factors.
Results
Diverse studies with different study designs, age groups, pulpal diagnoses, patient populations, VPT techniques, treatment protocols, and outcome measurements have examined postoperative pain after VPT. Significant heterogeneity exists among studies in the pain rating scale, timing of pain assessment, and reporting of pain incidence and intensity. None of the studies have examined postoperative pain after VPT as the primary outcome. The peak incidence of postoperative pain after VPT occurred on the first day, ranging from 26.8% to 79.1%. Patients commonly reported the pain as mild. This pain typically resolved within 7 days. Factors such as preoperative pain intensity, percussion pain, periapical lesions, and pulp dressing materials were identified as potential predictors for postoperative pain after VPT.
Conclusion
Understanding postoperative pain enhances clinicians’ proficiency, encouraging a more comprehensive, patient-centric VPT approach. This review fills a knowledge gap, offering valuable insights for practitioners. Recognizing the nuanced nature of pain dynamics allows clinicians to elevate their proficiency and provide optimal patient care with VPT. Future well-designed studies, focusing particularly on postoperative pain in children, will advance our understanding in this area.
1
Introduction
Vital pulp therapy (VPT) is a contemporary method for managing vital permanent teeth with deep caries [ ]. Supported by both endodontic and pediatric dental organizations [ ], its popularity has increased due to its high success rates, ability to preserve tooth vitality and function, simplified technique, reduced chair time, and cost-effectiveness. Combined with the ultimate goal of fostering a positive dental experience for children, all these factors make VPT a viable treatment option for pediatric patients [ ].
Traditional endodontic treatment has been associated with patient avoidance due to anticipated postoperative pain [ , ]. In contrast, limited information exists about postoperative pain after VPT in permanent teeth, especially in pediatric patients [ , ]. Recent studies [ ] with diverse patient demographics and using various research methodologies have begun to shed light on the multifaceted nature of post-VPT pain.
2
Significance of pain perception and postoperative pain in dentistry
The International Association for the Study of Pain has defined pain as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [ ]. This definition underscores the complex nature of pain perception and its significance in medical and dental contexts. In dentistry, pain information is vital in making diagnoses and anticipating the necessity for additional anesthetics and postoperative analgesics [ ]. Pain associated with pulpitis occurs when nociceptors, which are sensory pain receptors, are activated or sensitized by inflammatory and immune mediators released in response to microbial infections or injury. These mediators include cytokines, prostaglandins, and neuropeptides, which contribute to transmitting pain signals. Postoperative pain after VPT can be attributed to similar mechanisms. The treatment can induce a transient inflammatory response, triggering the release of inflammatory and immune mediators that can sensitize nociceptors and lead to pain perception [ ].
3
Literature search and scope of review
VPT techniques include indirect pulp capping, direct pulp capping, partial pulpotomy, and coronal pulpotomy [ ]. Among them, indirect pulp capping and direct pulp capping involves preserving the complete pulp, while partial pulpotomy and coronal pulpotomy involve partially preserving the pulp [ ]. The treatment aims to preserve pulp vitality, positively impacting tooth development. Existing studies have reported high success with all types of VPT [ ]. However, few studies have examined postoperative pain after VPT. The physiology of postoperative pain after VPT remains unknown. Moreover, factors associated with such pain also remain uncertain. Additionally, the effective relief of postoperative pain is a crucial aspect to consider when evaluating different endodontic treatment options, including VPT [ ].
In conducting this narrative review, a targeted literature search was performed in November 2023, by using keywords such as ‘postoperative pain,’ ‘vital pulp therapy,’ and ‘permanent teeth’ on PubMed. The search aimed to identify articles published between 2010 and 2023 that are relevant to the patient-reported postoperative pain after VPT. In this context, postoperative pain refers to the discomfort experienced from the conclusion of VPT procedures to 7 days afterward. The review aims to enhance understanding of postoperative pain after VPT by summarizing its incidence, intensity, duration, analgesic usage, and associated factors in a concise manner, extracting information that contributes to the overall comprehensiveness of the narrative. Furthermore, this review underscores the importance of recognizing and efficiently managing pain while advocating for adopting a holistic, patient-centered approach in VPT practice. Understanding postoperative pain enhances clinicians’ proficiency, encouraging a more comprehensive, patient-centric approach to patient care within the VPT field [ ].
The existing literature on postoperative pain after VPT includes diverse studies with various study designs, age groups, pulpal diagnoses, patient populations, VPT techniques, treatment protocols, and outcome measurements [ Table 1 ]. These studies usually reveal similarities in diagnostic factors, treatment procedures, and promising outcomes. However, there is notable heterogeneity in pain rating scales, timing of pain assessment, and reporting of pain incidence and intensity across the studies.
| First author (year), study type | Subject characteristics | Postoperative pain | VPT outcome | ||||||
|---|---|---|---|---|---|---|---|---|---|
| n | Age (years) | Pulpal diagnosis | VPT type | Pain scale | Time measured | Pain outcome measures | Results | ||
| Asgary and Eghbal (2010), randomized controlled trial [ ]. | 407 gr I: RCT (202) gr II: CP (205) |
Range: 9–65, Mean ± SD gr I: 26 ± 8 gr II: 27 ± 8 |
Irreversible pulpitis | CP | NRS (take-home questionnaire) | Pre-operative, 6-, 12-, 18-, 24-, 36-, 48-, 60-hr, 3-, 4-, 5-, 6-, 7-days |
Mean pain intensity in 7 days | Sig. difference between groups – gr I: 1.26 ± 0.08 – gr II: 0.67 ± 0.05 ( p < 0.001, t -test) |
At 1 year, clinical success RCT gr: 98.3 % CP gr: 97.6% radiographic Outcome as healed: RCT gr: 70.3 % CP gr: 92.2% healing: RCT gr: 10.9 % CP gr: 0.6 % |
| Distribution of pain level (pain-free, mild, mod., severe) | Sig. changes in 7 days – At day 7, most cases had no pain, while about 10% had only mild pain ( p < 0.001, repeated measures ANOVA) |
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| Time to pain-free status (median, 95% CI) | Sig. difference between groups – gr I: 36 h (27–45 h) – gr II: 18 h (15–21 h) ( p < 0.01, Kaplan–Meier [log-rank] test) |
At 2 years, radiographic Outcome as healed: RCT gr: 79.5% CP gr: 86.1% |
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| Distribution of patients taking postoperative analgesics | Sig. difference between groups – gr I > gr II for every analgesic type – gr II had a higher proportion of none taking than gr I ( p < 0.001, 2-way ANOVA) |
At 5 years, radiographic Outcome as healed: RCT gr: 75.3% CP gr: 78.1% |
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| Asgary et al. (2013), randomized controlled trial [ ]. | 412 gr I: CEM (205) gr II: MTA (207) |
Mean ± SD gr I: 27 ± 8 gr II: 26 ± 9 |
Irreversible pulpitis | CP | NRS (take-home questionnaire) | Pre-operative, 6-, 12-, 18-, 24-, 36-, 48-, 60-hr, 3-, 4-, 5-, 6-, 7-days |
Mean pain intensity at each time point | No sig. difference in mean pain intensity between groups at any time point ( p > 0.05, t -test) | At 1 year, clinical success CEM gr: 97.6% MTA gr: 98.3% radiographic Outcome as healed: CEM gr: 92.2% MTA gr: 95.5% healing: CEM gr: 0.6% MTA gr: 0.0 % |
| Asgary et al. (2018), randomized controlled trial [ ]. | 302 gr I: IPT (84) gr II: DPC (73) gr III: PP (76) gr IV: CP (69) |
Range: 12–75, Mean ± SD gr I: 26 ± 8 gr II: 28 ± 10 gr III: 27 ± 8 gr IV: 26 ± 7 |
Reversible or irreversible pulpitis with and without apical periodontitis or periapical lesions | IPT, DPC, PP, CP | NRS (take-home questionnaire) | pre-operative, 6-, 12-, 18-, 24-, 36-, 48-, 60-hr, 3-, 4-, 5-, 6-, 7-days |
Trend in postoperative pain over time | Sig. reduction over time ( p < 0.001, multifactorial repeated measured ANOVA, adjusted for baseline pain) | Overall success rates at 1 year: IPT gr: 100% DPC gr: 95.7% PP gr: 91.4% CP gr: 95.9% |
| Kumar et al. (2016), randomized controlled trial [ ]. | 42 gr I: CH (14) gr II: MTA (15) gr III: PRF (13) |
Mean (range) gr I: 17.82 (14–23) gr II: 21.20 (14–32) gr III: 25.81 (14–32) |
Symptomatic irreversible pulpitis | CP | NRS (reported by patient) | Pre-operative, 24 h, 7 days, 6 months, and 1 year |
Trend in postoperative pain over time | Sig. reduction in pain score from baseline to all tested time points in all groups. ( p < 0.005, Kruskal–Wallis test) | Overall success rates at 1 year: CH gr: 37.5% MTA gr: 44.4% PRF gr: 35.7%. |
| Galani et al. (2017), randomized controlled trial [ ]. | 50 gr I: CP (26) gr II: RCT (24) |
Range:15–50, Mean ± SD gr I: 26 ± 8 gr II: 27 ± 8 |
Symptomatic irreversible pulpitis | CP | 10-cm VAS | Pre-operative, every 24 h until the 7 days after the first appointment | Comparison of pain intensity changes between groups | No sig. difference in the mean PI scores between different study arms at all observation points. ( p > 0.05, Kruskal–Wallis test) | Overall success rates at 1 year: CP gr: 85% RCT gr: 87.5% |
| Mean pain intensity at each time point | Mean pain scores decreased in both groups, with the pulpotomy group experiencing less pain than the RCT group on all days. ( p < 0.05, Mann–Whitney U test) | ||||||||
| Trend over time | Sig. pain reduction in the pulpotomy group from the first to the fourth day. ( p < 0.05, Wilcoxon signed rank test) In the RCT group, pain reduction was not sig. until the second day, after which the results became significant until the seventh day. ( p > 0.05, Wilcoxon signed-rank test). |
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| Patients taking postoperative analgesics | Sig. difference between groups, with no patients in gr I taking analgesics. ( p < 0.05, Chi-squared test) | ||||||||
| Bagheri et al. (2019), randomized clinical trial [ ]. | 45 gr I: DC (15) gr II: MTA (15) gr III: DEX (15) |
Mean ± SD 28.47 ± 9.21 gr I: 30.47 ± 10.13 gr II: 28.87 ± 11.03 gr III: 26.07 ± 5.65 |
Symptomatic irreversible pulpitis | CP | VAS (take-home form) | 6-, 12-, 18-, 24-hr, 2-, 3-, 4-, 5-, 6-, 7-days after treatment | Comparison of pain intensity between groups | Sig. differences in VAS scores between the 3 treatment methods ( p = 0.014, ANOVA) – gr II: no post-treatment severe pain at any time interval except at 6 (20% cases) and 12 (5% cases) hr. – gr I, III: Severe pain was reported at all-time intervals |
N/A |
| Comparison within the treatment groups at 6 and 12 h | No sig. differences at 6 and 12 h post-treatment. ( p > 0.05, ANOVA) | ||||||||
| Eghbal et al. (2020), randomized controlled trial [ ]. | 550 gr I: MTA (188) gr II: CEM (194) gr III: RCT (168) |
Mean ± SD gr I: 29 ± 0.7 gr II: 30 ± 0.7 gr III: 29 ± 0.8 |
Irreversible pulpitis | CP | NRS (take-home questionnaire) | 6-, 12-,18-,24-, 36-hr, 3-, 4-, 5-, 6-, 7- days | Intensity changes within 7 days | Sig. reduction over time. ( p < 0.0001, repeated measure ANOVA). | N/A |
| Comparison of pain intensity between groups | No sig. difference. (interaction effect, P = 0.821) | ||||||||
| Comparison of pain severity between groups | No sig. difference ( p > 0.05, Kruskal–Wallis test) | ||||||||
| Mean and median time to pain-free status | No sig. difference between groups. ( p > 0.05, Kaplan–Meier [log-rank] test) | ||||||||
| Ballal et al. (2020), randomized controlled trial [ ]. | 48 gr I: NSS gr II: NaOCl |
Mean ± SD gr I: 38 ± 12 gr II: 30 ± 12 |
Normal pulp + extremely deep caries | DPC | NRS (phone call) | Pre-operative, 3 and 7 days | Comparison of the distribution of pain scores between groups at each time point | Sig. difference on days 3 and 7. – gr II < gr I on days 3 and 7 ( p = 0.0010 and 0.0007, Wilcoxon signed-rank test) |
Survival rate at 1500 days post-treatment: NSS gr: 7% NaOCl gr: 55% |
| Singh et al. (2020), randomized controlled trial [ ]. | 60 gr I; CH (20) gr II; MTA (20) gr III: PRF (20) |
Not reported | Symptomatic irreversible pulpitis | CP | NRS (reported by patient) | 24 h, 1 week, 3 months, 6 months, and 1 year | Comparison of pain scores between groups at each time point | No sig. difference in pain intensity at all times. ( p > 0.05, Kruskal–Wallis test) | Clinical success rates at 6 months: CH gr: 81.5% MTA gr: 82.4% PRF gr: 83.8% Radiographic success rates at 6 months: CH gr: 82.3% MTA gr: 83.4% PRF gr: 84.2% |
| Shallal-Ayzin et al. (2021), prospective observational study [ ]. | 73 | Range: 15–78 Median: 45 |
Asymptomatic irreversible pulpitis | PP and DPC | NRS (phone call) | 24 h, 1 week, 3 months | Incidence within 24 h | 65% of patients experienced pain | success rate at 6 months: 84.3% |
| Intensity after 3 months | Pain intensity decreased over time, with most patients (83%) pain-free after 3 months. | ||||||||
| Analgesic intake | 30%, 19%, and 9% of patients used analgesics at 24 h, 1 week, and 3 months, respectively. | ||||||||
| Koli et al. (2021), randomized controlled trial [ ]. | 60 gr I: RCT (30) gr II: RCT + VPT (30) |
Mean ± SD gr I: 24.5 ± 5.30 gr II: 24.8 ± 5.95 |
Symptomatic irreversible pulpitis with apical periodontitis |
CP | NRS (phone call) | Pre-operative and 24, 48, and 72 h after treatment | Comparison of the distribution of pain scores between groups at each time point | No sig. difference in pain scores between groups at 24- and 72-hr. ( p > 0.05, Friedman rank sum test) Sig. difference in pain scores between groups at 48-hr. ( p < 0.05, Friedman rank sum test) |
Success at 12-month: RCT group: 90% RCT + VPT gr: 93.3% |
| Elmas et al. (2023), cohort [ ]. | 48 | Range: 6–14 Mean: 9.6 |
Symptomatic irreversible pulpitis | CP | WBFPS (reported by patient) | Pre-operative and 2 days after treatment | Incidence | After 2 days, patients had no pain (WBFPS 0 = 62.6%) or mild pain (WBFPS 2 = 31.2%, WBFPS 4 = 4.2%) | Clinical success rates at 2 years: 97.5% |
| Trend over time | Sig. reduction over time. ( p < 0.001, Wilcoxon signed-rank test) | ||||||||
| Analgesic intake | No patients took analgesics. | ||||||||
| Taha et al. (2023), randomized controlled trial [ ]. | 60 gr I: CP (30) gr II: RCT (30) |
Mean ± SD gr I: 25.97 ± 10.23 gr II: 33.53 ± 9.69 |
Irreversible pulpitis | CP | NRS (phone call) | Pre-operative and 1, 2, 3, 5, and 7 days after treatment | Pain intensity | Sig. difference on day 1. gr I < gr II ( p = 0.037, independent t -test) No sig. difference on days 2, 3, and 5. |
Overall success rate at 1 year: CP gr: 93% RCT gr: 93% |
| Patients taking analgesics after treatment | Sig. difference = gr I < gr II. ( p = 0.028, Chi-square test) | ||||||||
| Tzanetakis et al. (2023), randomized controlled trial [ ]. | 137 gr I: MTA Angelus (74) gr II: Total Fill BC (63) |
Median (IQR): 36 (21) | Irreversible pulpitis | PP | VAS (reported by patient) | Pre-operative and seven days after treatment | Pain intensity | Most patients reported pain intensity at level 3 on the VAS (55/137; 40.1%). | Median follow- up time of MTA Angelus gr: 2.1 years (IQR: 1.8–2.8) Total Fill BC gr: 1.9 years (IQR: 1.6–2.3) Overall success rate: 94.4% |
| Pain duration | Median of 2 days (IQR: 2) | ||||||||
| patients taking analgesics after treatment | Patients taking analgesics after treatment = 103/137 (75.2%). | ||||||||
| Tzanetakis et al. (2023), prospective case series [ ]. | 34 | Range: 9–12 Median (IQR): 9 (9–10) |
Symptomatic irreversible pulpitis | PP | With or without pain (reported by patient) | Pre-operative and 2 days after treatment | Pain incidence | 23/34 (67.7%) did not report any pain. | Median follow up time of 2.4 years (IQR: 2.2–3.4) Overall success rate: 100% |
| Pain duration | 11/34 (32.3%) reported pain only for 1 day. | ||||||||
| patients taking analgesics after treatment | 10/34 (29.4%) took analgesics after treatment. | ||||||||
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