Clinical Research| Volume 47, ISSUE 9, P1376-1382, September 2021

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Associations between Pain Severity, Clinical Findings, and Endodontic Disease: A Cross-Sectional Study

  • Ozge Erdogan
    Address requests for reprints to Ozge Erdogan, Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115.
    Division of Endodontics in Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, Massachusetts

    Department of Endodontics, New York University, College of Dentistry, New York, New York
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  • Matthew Malek
    Department of Endodontics, New York University, College of Dentistry, New York, New York
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  • Jennifer L. Gibbs
    Division of Endodontics in Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, Massachusetts

    Department of Endodontics, New York University, College of Dentistry, New York, New York
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      Thorough pain assessment and thermal and mechanical testing are the primary diagnostic tools used to assess the status of pulp and periapical tissues in teeth with potential endodontic pathology. This study evaluated predictors of acute odontogenic pain to better understand the relationship between endodontic pain, clinical testing, endodontic disease, and diagnoses.


      Participants (N = 228) presenting with acute odontogenic pain underwent standardized clinical testing and reported their pain intensity. Univariate and multiple regression analyses were performed to evaluate the predictors of acute endodontic pain. Chi-square tests with Bonferroni adjustments were conducted to measure the frequency of endodontic diagnostic test findings and clinical observations in patients with different pulpal diagnoses.


      A negative response to cold stimulation on the causative tooth and percussion hypersensitivity on the healthy adjacent tooth were the strongest predictors of higher levels of acute endodontic pain. Percussion hypersensitivity on the healthy adjacent tooth was present in a quarter of the cohort and was reported with equal frequency in teeth diagnosed with irreversible pulpitis, necrotic pulp, and previously initiated/treated teeth. Although painful percussion on the causative tooth was more frequently reported in teeth diagnosed with necrotic pulp, painful palpation was more frequently reported on teeth diagnosed with previously initiated/treated teeth.


      Percussion hypersensitivity on the healthy adjacent tooth may reveal a lowered pain threshold and heightened pain sensitization. It is also possible that the 2 commonly performed mechanical sensory tests, percussion and palpation hypersensitivity, may detect different aspects of endodontic pathophysiology and pain processing.

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        • Cachovan G.
        • Phark J.H.
        • Schon G.
        • et al.
        Odontogenic infections: an 8-year epidemiologic analysis in a dental emergency outpatient care unit.
        Acta Odontol Scand. 2013; 71: 518-524
        • Toure B.
        • Kane A.W.
        • Diouf A.
        • et al.
        Preoperative pain and medications used in emergency patients with irreversible acute pulpitis or acute apical periodontitis: a prospective comparative study.
        J Orofac Pain. 2007; 21: 303-308
        • Gutmann J.L.
        • Baumgartner J.C.
        • Gluskin A.H.
        • et al.
        Identify and define all diagnostic terms for periapical/periradicular health and disease states.
        J Endod. 2009; 35: 1658-1674
        • Michaelson P.L.
        • Holland G.R.
        Is pulpitis painful?.
        Int Endod J. 2002; 35: 829-832
        • Levin L.G.
        • Law A.S.
        • Holland G.R.
        • et al.
        Identify and define all diagnostic terms for pulpal health and disease states.
        J Endod. 2009; 35: 1645-1657
        • Jespersen J.J.
        • Hellstein J.
        • Williamson A.
        • et al.
        Evaluation of dental pulp sensibility tests in a clinical setting.
        J Endod. 2014; 40: 351-354
        • Mainkar A.
        • Kim S.G.
        Diagnostic accuracy of 5 dental pulp tests: a systematic review and meta-analysis.
        J Endod. 2018; 44: 694-702
        • Pigg M.
        • Nixdorf D.R.
        • Nguyen R.H.
        • et al.
        Validity of preoperative clinical findings to identify dental pulp status: a National Dental Practice-Based Research Network study.
        J Endod. 2016; 42: 935-942
        • Owatz C.B.
        • Khan A.A.
        • Schindler W.G.
        • et al.
        The incidence of mechanical allodynia in patients with irreversible pulpitis.
        J Endod. 2007; 33: 552-556
        • Law A.S.
        • Nixdorf D.R.
        • Aguirre A.M.
        • et al.
        Predicting severe pain after root canal therapy in the National Dental PBRN.
        J Dent Res. 2015; 94: 37S-43S
        • Kayaoglu G.
        • Ekici M.
        • Altunkaynak B.
        Mechanical allodynia in healthy teeth adjacent and contralateral to endodontically diseased teeth: a clinical study.
        J Endod. 2020; 46: 611-618
        • Erdogan O.
        • Malek M.
        • Janal M.N.
        • Gibbs J.L.
        Sensory testing associates with pain quality descriptors during acute dental pain.
        Eur J Pain. 2019; 23: 1701-1711
        • Jensen M.P.
        • Dworkin R.H.
        • Gammaitoni A.R.
        • et al.
        Assessment of pain quality in chronic neuropathic and nociceptive pain clinical trials with the neuropathic pain scale.
        J Pain. 2005; 6: 98-106
        • Nusstein J.M.
        • Beck M.
        Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 96: 207-214
        • Renard E.
        • Gaudin A.
        • Bienvenu G.
        • et al.
        Immune cells and molecular networks in experimentally induced pulpitis.
        J Dent Res. 2016; 95: 196-205
        • Sasaki H.
        • Furusho H.
        • Rider D.B.
        • et al.
        Endodontic infection-induced inflammation resembling osteomyelitis of the jaws in Toll-like receptor 2/interleukin 10 double-knockout mice.
        J Endod. 2019; 45: 181-188
        • Rossi H.L.
        • See L.P.
        • Foster W.
        • et al.
        Evoked and spontaneous pain assessment during tooth pulp injury.
        Sci Rep. 2020; 10: 2759
        • Rechenberg D.K.
        • Held U.
        • Burgstaller J.M.
        • et al.
        Pain levels and typical symptoms of acute endodontic infections: a prospective, observational study.
        BMC Oral Health. 2016; 16: 61
        • Emrick J.J.
        • von Buchholtz L.J.
        • Ryba N.J.
        Transcriptomic classification of neurons innervating teeth.
        J Dent Res. 2020; 99: 1478-1485
        • Fried K.
        • Sessle B.J.
        • Devor M.
        The paradox of pain from tooth pulp: low-threshold "algoneurons"?.
        Pain. 2011; 152: 2685-2689
        • Gibbs J.L.
        • Melnyk J.L.
        • Basbaum A.I.
        Differential TRPV1 and TRPV2 channel expression in dental pulp.
        J Dent Res. 2011; 90: 765-770
        • Park S.K.
        • Choi S.K.
        • Kim Y.G.
        • et al.
        Parvalbumin-, substance P- and calcitonin gene-related peptide-immunopositive axons in the human dental pulp differ in their distribution of varicosities.
        Sci Rep. 2020; 10: 10672
        • Murthy S.E.
        • Loud M.C.
        • Daou I.
        • et al.
        The mechanosensitive ion channel Piezo2 mediates sensitivity to mechanical pain in mice.
        Sci Transl Med. 2018; 10: eaat9897
        • Szczot M.
        • Liljencrantz J.
        • Ghitani N.
        • et al.
        PIEZO2 mediates injury-induced tactile pain in mice and humans.
        Sci Transl Med. 2018; 10: eaat9892
        • Alelyani A.A.
        • Azar P.S.
        • Khan A.A.
        • et al.
        Quantitative assessment of mechanical allodynia and central sensitization in endodontic patients.
        J Endod. 2020; 46: 1841-1848
        • Matsuda M.
        • Huh Y.
        • Ji R.R.
        Roles of inflammation, neurogenic inflammation, and neuroinflammation in pain.
        J Anesth. 2019; 33: 131-139
        • Cobos E.J.
        • Nickerson C.A.
        • Gao F.
        • et al.
        Mechanistic differences in neuropathic pain modalities revealed by correlating behavior with global expression profiling.
        Cell Rep. 2018; 22: 1301-1312
        • Latremoliere A.
        • Woolf C.J.
        Central sensitization: a generator of pain hypersensitivity by central neural plasticity.
        J Pain. 2009; 10: 895-926
        • Fillingim R.B.
        • King C.D.
        • Ribeiro-Dasilva M.C.
        • et al.
        Sex, gender, and pain: a review of recent clinical and experimental findings.
        J Pain. 2009; 10: 447-485
        • Mogil J.S.
        Sex differences in pain and pain inhibition: multiple explanations of a controversial phenomenon.
        Nat Rev Neurosci. 2012; 13: 859-866
        • Farac R.V.
        • Morgental R.D.
        • Lima R.K.
        • et al.
        Pulp sensibility test in elderly patients.
        Gerodontology. 2012; 29: 135-139
        • Wilder-Smith O.H.
        • Tassonyi E.
        • Arendt-Nielsen L.
        Preoperative back pain is associated with diverse manifestations of central neuroplasticity.
        Pain. 2002; 97: 189-194