Endodontic Emergency Patients’ Profile and Treatment Outcome – A Prospective Cohort Study

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This study aims to delineate the profiles of patients seeking emergency dental care, focusing on the diagnosis, treatment, and outcomes following non-surgical root canal treatment. Methods This prospective cohort study was conducted from 2012 to 2021 at the Section for Endodontics, Department of Clinical Dentistry, University of Bergen, Norway. A total of 281 emergency patient forms were analyzed. Data registered included patient demographics, dental history, chief complaints, medications used, diagnostic results, treatments provided and outcome. Results A total of 272 patients (272 teeth) were included in the study. Pain was the predominant complaint (98.5%), where only 57.4% of the patients managed to localize pain to a specific tooth. The mean age of patients was 51.2 years with no significant gender differences. The maxillary right first molar (41.9%) was the most frequent tooth needing treatment. The majority of the patients had experienced pain for three days before they attended the emergency appointment. The most frequently used drug for pain management was paracetamol which was stated to have little effect. Teeth that needed endodontic treatment often had fillings rather than caries. The most frequent diagnoses were pulpitis (26.8%) followed by necrotic pulp (25.2%) and previously root-filled teeth (22.8%). Root canal treatment was performed on 62.5% of the teeth and a success rate of 95% was registered at one-year recall. Conclusions There was no singular diagnostic cause leading patients to seek an emergency appointment, highlighting the necessity of a thorough diagnostic procedure. Over the counter pain medications have little effect on alleviating dental pain, often resulting in desperate measures of self-medication. Restorative treatments, such as fillings or crowns, do not appear to protect against future pulpal disease. The good prognosis of root canal treatment for teeth with acute symptoms supports recommending dentists to attempt root canal treatment rather than opting for tooth extraction. Pain diagnosis decision making Pulpotomy Prognosis Outcome Figures Figure 1 Figure 2 Figure 3 Background Toothache is a debilitating condition that often drives people to seek emergency dental treatment. A study from Denmark indicated that endodontic-related infections were responsible for dental pain in 66% of the patients who sought treatment [ 1 ]. If left untreated, infection in a dental pulp can spread to the alveolar bone, soft tissue, muscles and even into the bloodstream. In the United States, approximately 7,000 patients are hospitalized annually due to complications from endodontic infections [ 2 ]. In the most severe cases, these infections or resultant septicemia can be fatal [ 3 – 5 ]. Historical records, such as the "Bills of Mortality" from early 17th-century London, show that dental problems were among the top six causes of death at the time [ 6 , 7 ]. Dental professionals often encounter patients who require emergency treatment that cannot be delayed until a scheduled appointment. Our previous research has identified a psychosocial component to acute dental pain. Stress, whether originating from home or the workplace, can activate the immune system and exacerbate an existing asymptomatic endodontic condition [ 8 ]. Patients experiencing acute dental pain have been found to exhibit elevated levels of salivary cortisol—a hormone that increases under stress—along with inflammatory mediators such as interleukin-1β (IL-1β) and IL-6 [ 8 ]. In addition, a study by Dahlström in 2016, revealed that general dental practitioners often experience stress, frustration, and a sense of lack of control during endodontic procedures [ 9 ]. Needless to say, it may be challenging for a dental practitioner to diagnose and perform emergency treatment within a limited time in situations when a patient turns up with pain and/or swelling [ 10 ]. It may also represent a diagnostic challenge that patients with excruciating dental pain often have difficulties localizing pain to a specific tooth. To provide optimal treatment, diagnosis needs to be established following a clinical and radiographic examination. An interim treatment plan should be devised for the acute phase to alleviate the patient's symptoms, followed by a formulation of a permanent or definitive treatment plan, often including multi-disciplinary and economic considerations. Research regarding emergency treatment in the field of Endodontics is limited, making it imperative to prioritize this area of study. Enhanced understanding and knowledge will ultimately lead to improved treatment options and outcomes for patients. The objectives for emergency treatment can be divided into short-term and long-term goals. The immediate focus is to alleviate pain, control infection, and prevent systemic complications. The long-term objective is to prevent re-infection in the root canal system and alveolar bone [ 11 ]. Research has demonstrated that preserving a tooth through endodontic treatment contributes to a better quality of life compared to extraction [ 12 , 13 ]. Patients seek dental treatment for a variety of reasons. Within the context of this study, emergency treatment refers to instances where patients have a dental problem that, according to them, cannot wait for a scheduled appointment. The aim of this study was to establish a comprehensive profile of patients attending emergency dental appointments. This includes documenting signs and symptoms, identification of affected teeth, the diagnostic process, medication used, and the assessment of both emergency and definitive treatment plans. Additionally, the study will examine the outcomes of root canal treatments provided under these emergency conditions. Methods This study is a prospective cohort study conducted from 2012 to 2021. It included all patients who attended an emergency dental appointment at the Section for Endodontics, Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Norway. The patients were registered using an Emergency Patient form, designed to record profiles of patients receiving emergency dental care, including their diagnosis and both interim and permanent treatment plans. Dental students attended to these patients were responsible for filling out the Emergency Patient form and a quality control was conducted by the clinical instructors. The information from the Emergency Patient forms was anonymized and transferred to an Excel file. Additional information for clarification and treatment outcomes was collected from the patient records. Throughout this process, all regulations for GDPR, as legally mandated by the EU for all EU and EEA countries, were strictly adhered to. The research protocol was approved by the Regional Committees for Medical and Health Research Ethics West, Norway as a quality assurance study (REK 617936). Inclusion and exclusion criteria During the period under review, a total of 281 forms were collected and included in this study. However, nine of these forms missed the patient's registration number and were consequently excluded from the study. As a result, 272 forms were finally included in the analysis. Statistical Analyses Student t test and Mann-Whitney rank sum test were used to determine statistically significant differences between groups. All analyses were performed using Statistical Package for the Social Sciences (SPSS, version 26.0, IBM). A p value of 0.05% was considered statistically significant. Results A total of 272 (143 male and 129 female) patients with 272 teeth was included in the study, showing no significant gender difference. The average age of patients seeking emergency treatment was 51.2 years, ranging from 20 to 90 years. The most frequent age group attending an emergency appointment was patients over 65 years, accounting for 29.9% of cases, although no significant differences between the age groups were observed (Fig. 1 ). The tooth most commonly requiring emergency treatment was the maxillary right first molar (15.4%), followed by the maxillary left first molar and the mandibular right and left first molars, respectively (Fig. 2 ). Of all the teeth involved, 61% were located in the maxilla and 39% in the mandible. Teeth that did not present with any emergency problems included the mandibular lateral incisors and the maxillary left third molar. Pain is the most frequent chief complaint by patients (Table 1 ). Other symptoms included pain on biting or chewing, pain-related sleep disturbances, pain consuming hot or cold beverages or food, swelling and fever (Table 1 ). The duration of pain experienced by patients varied widely, ranging from 4 hours and 4 years with a mean of 49.1 ± 36.9 days. The most frequent day for seeking emergency appointment was on day 3 (13.6%) following onset of pain. More than half the patients (51.1%) sought emergency appointment within one week, 70.6% of patients took contact for emergency treatment within one month, 14.3% of patients waited for 3 months or longer before seeking help (Fig. 3 ). Table 1 Symptoms reported by patients as a reason for emergency appointment. Several patients reported more than one symptom. Symptoms Frequency Percent (%) Pain 268 98.5 Pain when biting/chewing 168 61.8 Insomnia (due to pain) 155 57.0 Worsening of pain sensation with hot or cold drinks 110 40.4 Swelling 67 24.6 Fever 19 7.0 A significant portion of the patients, 176 or 64.7%, used one or more types of medications to alleviate pain prior to their emergency appointment (Table 2 ). Of these patients, 61.4% took one type of medication, 34.7% used two types, and 3.9% combined three different medications. The self-administered medications included over-the-counter analgesics, antibiotics, opioids, among others (Table 2 ). The most commonly used analgesic was paracetamol, utilized by 61.9% of those who took medications. Patients often resorted to taking combination drugs or stronger painkillers, as over-the-counter medications did not provide sufficient pain relief. Table 2 Overview of medications used by patients for pain relief. Medications Number of patients Percentage (%) Analgesics Paracetamol 109 39.0 NSAIDS Ibuprofen 88 32.4 Voltarol (Diclofenac) 1 0.4 Disbril (Aspirin) 1 0.4 Retard 1 0.4 Antibiotics Apocillin 5 1.8 Amoxicillin 2 0.7 Dalacin 1 0.4 Uspecified 1 0.4 Metronidazol 1 0.4 Opioides Tramadol 2 0.7 Codaxol (paracetamol with codeine) 1 0.4 Paralgin forte (paracetamol with codeine) 24 8.8 Pinex forte (paracetamol with codeine) 7 2.6 Morphine 1 0.4 Buprenorphine 1 0.4 Other medications Imovane (Z-drug hypnotics) 1 0.4 Sobril (benzodiazepam) 1 0.4 Only 156 patients, or 57.4%, were able to accurately localize the pain to a specific tooth (Table 3 ). The majority of these teeth had restorations (61.8%), while only 19.1% presented with carious lesions. The most frequent pulp diagnosis was pulpitis (26.8%), followed by pulp necrosis (25.4%) and previously treated teeth (22.8%). The remaining patients presented with pain from periodontal disease or problems associated with fractured or missing fillings. Table 3 The patient demographic information. Recurrent caries on teeth with restorations and prosthodontics was registered as caries. Variables Categories Frequency n (%) Pain localization Single tooth 2–5 teeth One quadrant Two quadrants 156 (57.4) 33 (12.1) 79 (29.0) 4 (1.5) Coronal status Restoration Crown/bridge abutment Caries 168 (61.8) 55 (20.2) 52 (19.1) Pulp diagnosis Pulpitis Pulp necrosis Previous root-filled tooth Others 73 (26.8) 69 (25.4) 62 (22.8) 68 (25.0) The most common emergency treatment plan was pulpotomy (25.4%), followed by medications (20.6%), and root canal instrumentation for necrotic cases (16.9%) (Table 4 ). The definitive treatment that the patients received is presented in Table 5 . In total, 170 teeth underwent root canal treatment, and 109 patients returned for a one-year follow-up appointment. Of these, 103 teeth (95%) were evaluated to have had a successful outcome, 2% were considered uncertain, and 3% were classified as failures (Table 6 ). Table 4 Emergency treatment plan. Since several patients received more than one treatment the total is more than the patient number in the study. Emergency treatment plan Number Percentage (%) Pulpotomy 69 25.4 Medications/Drugs 56 20.6 Root canal instrumentation (necrotic pulp) 46 16.9 Restorative treatment 25 9.2 Extraction 25 9.2 Referral to other specialities 22 8.1 Observation 21 7.7 Periodontal therapy 7 2.6 Retreatment 7 2.6 Table 5 The definitive treatment patients received. Since several patients received more than one treatment, the total is more than the patient number in the study. Definitive treatment Number Percentage (%) Root canal treatment 170 62.5 Extraction 39 14.3 No treatment 22 8.1 Patient did not return 18 6.6 Restorative or prosthodontic treatment 14 5.1 Periodontal therapy 9 3.3 Surgical treatment (hemi-section, root amputation or endodontic surgery) 7 2.6 Table 6 Treatment outcome for teeth that received root canal treatment. Outcome Number Percentage (%) Successful 103 95 Uncertain 2 2 Failure 4 3 Total 109 100 Discussion The main findings of this study indicated that patients often delayed seeking an emergency dental appointment until experiencing significant pain, which served as the primary motivating factor. Restorative treatments, such as fillings or crowns, do not fully protect against pulpal disease. A notable proportion of cases requiring emergency treatment involved previously root-filled teeth. Additionally, patients across all age groups experienced pain, with first molars being the most commonly problematic teeth. The dental pulp, when inflamed, is capable of eliciting extreme pain, reaching the highest scores on pain rating scales [ 14 ]. On the other hand, a necrotic dental pulp is theoretically incapable of giving rise to pain sensation. Interestingly, this study found nearly equal incidences of pulpitis and pulp necrosis. As the disease progresses within the dental pulp, both vital tissue and necrotic remnants may be found, leading to diagnoses such as partial necrosis or pulp necrobiosis. Additionally, a necrotic pulp can lead to symptomatic apical periodontitis, manifesting as pain during biting and chewing [ 15 ]. The most frequent day for seeking emergency appointment was 3 days which is in agreement with Another unexpected finding in this study was the complications associated with previously root filled teeth. A previously root filled tooth can fail due to problems associated with coronal restorations, the root filling itself, root fractures or periodontal problems. With more patients choosing to retain their natural teeth, a rise in retreatments of previously root-filled teeth is expected. The quality of root canal treatment is imperative to a successful treatment outcome. Therefore, root canal treatments should adhere to a high standard of care during primary procedures. A study from Norway concerning endodontic treatment needs in general dental practice revealed that 11.6% of cases were related to previously root-filled teeth, a finding that coincides with this study where 9.5% of the planned permanent treatments involved surgical and non-surgical retreatments [ 16 ]. The most frequent teeth requiring emergency dental treatment were the first molars. This finding is perhaps expected, as these teeth erupt around the age of six and have been in function for the longest period. On the other hand, the incisors in the lower jaw, which erupt at the same time, exhibit the lowest frequency of emergency cases. This discrepancy suggests that multiple factors influence the frequent occurrence of issues with molars. Possible explanations include differences in anatomical complexity and their position within the oral cavity. A study investigating caries prevalence in permanent dentition noted that teeth with deep and complex fissures were at the highest risk [ 17 ]. Similarly, it was found that teeth in the upper jaw were more frequently affected by caries than those in the lower jaw, agreeing with the findings of this study and our previous research [ 18 , 19 ]. No gender differences were observed among patients seeking emergency care, which is consistent with findings from a study by Haug and Marthinussen, indicating that women and men experience similar levels of pain related to pulpal and periapical inflammation [ 8 ]. Additionally, no specific age group was disproportionately affected, as the age range of patients stretched from 20 to 90 years, suggesting that individuals of all ages experience dental pain and require emergency dental care. A study on dental emergencies in Finland pointed out that carious lesions and its sequelae were the primary causation [ 20 ]. However, in this study, most of the affected teeth had undergone some form of previous restorative treatment, with many patients displaying fillings. This highlights that patients who make regular dental visits, unfortunately, may face emergency situations. It highlights the reality that restorative treatments, such as fillings or crowns, do not fully protect against pulpal disease. In this study, most commonly used medication to alleviate pain was paracetamol, followed by ibuprofen, a finding similar to our previous study [ 8 ]. A surprising observation was the wide variety of drugs used by patients for pain relief, including opioids and antibiotics. This diversity in self-medication underscores the need for more effective analgesics to alleviate dental pain. Our previous study reported that 83% of patients reported insomnia despite taking pain killers [ 8 ]. Additionally, the desperation to relieve pain emphasizes the substantial impact of dental pain on oral health-related quality of life. Furthermore, a study on individuals suffering from insomnia demonstrated that sleep disturbances significantly deteriorate their quality of life [ 23 ]. Living with pain significantly affects individuals' ability to function well both physically and mentally [ 21 , 22 ]. Most patients cited pain sensation as their primary reason for seeking emergency treatment, with about 70% experiencing pain severe enough to necessitate medication. Consequently, the goals of emergency dental treatment is to relieve pain, control or prevent infection and enhance patients' well-being and quality of life. Despite the fact that root canal treatment was performed on patients with preoperative pain and other symptoms, the treatment outcome was largely successful. A favorable prognosis for root canal treatment of teeth presenting for emergency treatment provides grounds for recommending dentists to perform root canal treatment rather than extraction. One of the limitations of this study is that the undergraduate clinic treats only adult patients, and as a result, children and dental trauma patients are not represented. Although the patient cohort at the Department of Clinical Dentistry may not be representative of the general population, the patients attending regular dental treatment at educational institutions can be comparable to a large private practice consisting of general practitioners and specialists. Future studies should focus on educating patients about when to seek dental treatment and on discovery of better medications that can alleviate dental pain. Conclusions There was no singular diagnostic cause leading patients to seek an emergency appointment, highlighting the necessity of a thorough diagnostic procedure. Over the counter pain medications have little effect on alleviating dental pain, often resulting in desperate measures of self-medication. Restorative treatments, such as fillings or crowns, do not appear to protect against future pulpal disease. The good prognosis of root canal treatment for teeth with acute symptoms supports recommending dentists to attempt root canal treatment rather than opting for tooth extraction. Declarations Declarations of interest: none The research protocol was approved by the Regional Committees for Medical and Health Research Ethics West, Norway as a quality assurance study (REK 617936). The authors declare that they have no competing interests. This research is supported by the Department of Clinical Dentistry, The Medical Faculty, University of Bergen, Norway. Here is the CRediT author statement: Sivakami Rethnam Haug: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; and Writing - review & editing. Margrethe Røegh: Conceptualization, Formal analysis, Methodology; Investigation, Resources, Validation; Visualization; Writing-Original Draft Inge Fristad: Project administration, Resources, Investigation, Supervision, Review & Editing Contributing authors information: Margrethe Røegh Department of Clinical Dentistry, The Medical Faculty, University of Bergen Email address: [email protected] Prof. Inge Fristad Department of Clinical Dentistry, The Medical Faculty, University of Bergen Email address: [email protected] Acknowledgements Not applicable References Sindet‐Pedersen S, Petersen, J. K., & Götzsche, P. C. Incidence ot pain conditions in dental practice in a Danisin county. 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Dahlström L, Lindwall, O., Rystedt, H., Reit, C. ‘Working in the dark’: Swedish general dental practitioners on the complexity of root canal treatment. International Endodontic Journal 2017;50:636–645. Dorn SO MR, Feldman MJ, Borden BG. Treatment of the endodontic emergency: a report based on a questionnaire-part I. J Endodont 1977;3:94-100. Carrotte P. Endodontics: Part 3. Treatment of endodontic emergencies. Br Dent J 2004;197:299-305. Wigsten E, Kvist T, Jonasson P, EndoReCo, Davidson T. Comparing Quality of Life of Patients Undergoing Root Canal Treatment or Tooth Extraction. J Endod 2020;46:19-28 e11. Neelakantan P, Liu P, Dummer PMH, McGrath C. Oral health–related quality of life (OHRQoL) before and after endodontic treatment: a systematic review. Clinical Oral Investigations 2020;24:25-36. Närhi M BL, Pigg M, Fristad I, Haug SR. Acute dental pain I: pulpal and dentinal pain. Nor Tannlegeforen Tid 2016;1:10-18. Sundqvist G. Bacteriological studies of necrotic dental pulps. Umeå University; 1976. Debelian G DL, Gerner N.W, Lange E, Pedersen I, Ulstad J, Bjørntvedt S, Willumsen T. Endodontisk sykdom hos pasienter som oppsøker allmentannleger i Norge. Nor Tannlegeforen Tid 2013;123:254-257. Demirci M, Tuncer, S., Yuceokur, A. A. Prevalence of caries on individual tooth surfaces and its distribution by age and gender in university clinic patients. European journal of dentistry 2010;4:270-279. Johnsen I, Bardsen A, Haug SR. Impact of Case Difficulty, Endodontic Mishaps, and Instrumentation Method on Endodontic Treatment Outcome and Quality of Life: A Four-Year Follow-up Study. J Endodont 2023;49:382-389. Zilinskaite-Petrauskiene I, Haug SR. A Comparison of Endodontic Treatment Factors, Operator Difficulties, and Perceived Oral Health-related Quality of Life between Elderly and Young Patients. J Endodont 2021;47:1844-1853. Widström E, Pietilä, I, Nilsson, B. Diagnosis and treatment of dental emergencies in two Finnish cities. Community Dental Health 1990;7:173-178. McCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey. Am J Ther 2008;15:312-320. Niv D, Kreitler S. Pain and quality of life. Pain Pract 2001;1:150-161. Ishak WW, Bagot K, Thomas S, Magakian N, Bedwani D, Larson D, et al. Quality of life in patients suffering from insomnia. Innov Clin Neurosci 2012;9:13-26. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2024 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 02 Jul, 2024 Editor assigned by journal 27 Jun, 2024 Submission checks completed at journal 27 Jun, 2024 First submitted to journal 23 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4625918","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321515921,"identity":"cf7107f8-44dc-4844-b4dc-b16a4c061154","order_by":0,"name":"Sivakami Rethnam Haug","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDACZgYGxgYGBh4GCRCvgoHHgEQtZ4jRwgDRwgDWwtjGwEBQi3w7j+HHGTXbZBikm59Jfp13WMacgffgA3xaDA7zGEtuOHabh0HmmJm07LbDPJYNfMl4bTJgZkuQfMAG1CKRYCYtCdRicIDHTAKvw5rZkn8++AfSkv5NWnIOEVoYDjMfk9zYBtKSYyb5sYEILQZALZYz+27zsEnkFFszHEvnsWzmMcbrF/n+g803e77dtueXSN9480eNtb05e4/hA7wOgwE2IGbmAbGYiVIPBYw/SFE9CkbBKBgFIwYAAFL3QVESA5guAAAAAElFTkSuQmCC","orcid":"","institution":"University of Bergen","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sivakami","middleName":"Rethnam","lastName":"Haug","suffix":""},{"id":321515922,"identity":"8c52f59b-0393-4ebc-ac6a-96e528f28786","order_by":1,"name":"Margrethe Røegh","email":"","orcid":"","institution":"University of Bergen","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Margrethe","middleName":"","lastName":"Røegh","suffix":""},{"id":321515923,"identity":"bc6a4c6f-547b-4653-94d1-0e9cc6a85b7b","order_by":2,"name":"Inge Fristad","email":"","orcid":"","institution":"University of Bergen","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Inge","middleName":"","lastName":"Fristad","suffix":""}],"badges":[],"createdAt":"2024-06-23 16:02:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4625918/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4625918/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-024-05338-8","type":"published","date":"2024-12-26T15:56:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60710546,"identity":"fdb2b571-5a70-41a4-bf5a-6d4e8deba0c8","added_by":"auto","created_at":"2024-07-19 20:06:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":139075,"visible":true,"origin":"","legend":"\u003cp\u003eAge distribution of patients.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4625918/v1/37db5e7aabb2c31fac251252.png"},{"id":60710545,"identity":"f8a842d9-8384-4400-9941-622d7b706e13","added_by":"auto","created_at":"2024-07-19 20:06:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":189088,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of tooth that was the reason for the emergency appointment.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4625918/v1/81d7e05610458d836140af87.png"},{"id":60710547,"identity":"a9bf8574-1631-467f-9a8e-935dd9ca82c1","added_by":"auto","created_at":"2024-07-19 20:06:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":247910,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of days the patients experienced pain before they attended the emergency appointment.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4625918/v1/c37bdae040254e4b8815cda1.png"},{"id":72640727,"identity":"de1f3634-a388-4aca-a818-14a5c591b5d2","added_by":"auto","created_at":"2024-12-30 16:09:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":992595,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4625918/v1/eb091a09-ec4a-48c5-a03f-b726741d381e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endodontic Emergency Patients’ Profile and Treatment Outcome – A Prospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003eToothache is a debilitating condition that often drives people to seek emergency dental treatment. A study from Denmark indicated that endodontic-related infections were responsible for dental pain in 66% of the patients who sought treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. If left untreated, infection in a dental pulp can spread to the alveolar bone, soft tissue, muscles and even into the bloodstream. In the United States, approximately 7,000 patients are hospitalized annually due to complications from endodontic infections [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the most severe cases, these infections or resultant septicemia can be fatal [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Historical records, such as the \"Bills of Mortality\" from early 17th-century London, show that dental problems were among the top six causes of death at the time [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDental professionals often encounter patients who require emergency treatment that cannot be delayed until a scheduled appointment. Our previous research has identified a psychosocial component to acute dental pain. Stress, whether originating from home or the workplace, can activate the immune system and exacerbate an existing asymptomatic endodontic condition [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Patients experiencing acute dental pain have been found to exhibit elevated levels of salivary cortisol\u0026mdash;a hormone that increases under stress\u0026mdash;along with inflammatory mediators such as interleukin-1β (IL-1β) and IL-6 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, a study by Dahlstr\u0026ouml;m in 2016, revealed that general dental practitioners often experience stress, frustration, and a sense of lack of control during endodontic procedures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Needless to say, it may be challenging for a dental practitioner to diagnose and perform emergency treatment within a limited time in situations when a patient turns up with pain and/or swelling [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It may also represent a diagnostic challenge that patients with excruciating dental pain often have difficulties localizing pain to a specific tooth. To provide optimal treatment, diagnosis needs to be established following a clinical and radiographic examination. An interim treatment plan should be devised for the acute phase to alleviate the patient's symptoms, followed by a formulation of a permanent or definitive treatment plan, often including multi-disciplinary and economic considerations. Research regarding emergency treatment in the field of Endodontics is limited, making it imperative to prioritize this area of study. Enhanced understanding and knowledge will ultimately lead to improved treatment options and outcomes for patients.\u003c/p\u003e \u003cp\u003eThe objectives for emergency treatment can be divided into short-term and long-term goals. The immediate focus is to alleviate pain, control infection, and prevent systemic complications. The long-term objective is to prevent re-infection in the root canal system and alveolar bone [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Research has demonstrated that preserving a tooth through endodontic treatment contributes to a better quality of life compared to extraction [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Patients seek dental treatment for a variety of reasons. Within the context of this study, emergency treatment refers to instances where patients have a dental problem that, according to them, cannot wait for a scheduled appointment.\u003c/p\u003e \u003cp\u003eThe aim of this study was to establish a comprehensive profile of patients attending emergency dental appointments. This includes documenting signs and symptoms, identification of affected teeth, the diagnostic process, medication used, and the assessment of both emergency and definitive treatment plans. Additionally, the study will examine the outcomes of root canal treatments provided under these emergency conditions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is a prospective cohort study conducted from 2012 to 2021. It included all patients who attended an emergency dental appointment at the Section for Endodontics, Department of Clinical Dentistry, Faculty of Medicine, University of Bergen, Norway. The patients were registered using an Emergency Patient form, designed to record profiles of patients receiving emergency dental care, including their diagnosis and both interim and permanent treatment plans.\u003c/p\u003e \u003cp\u003eDental students attended to these patients were responsible for filling out the Emergency Patient form and a quality control was conducted by the clinical instructors. The information from the Emergency Patient forms was anonymized and transferred to an Excel file. Additional information for clarification and treatment outcomes was collected from the patient records. Throughout this process, all regulations for GDPR, as legally mandated by the EU for all EU and EEA countries, were strictly adhered to. The research protocol was approved by the Regional Committees for Medical and Health Research Ethics West, Norway as a quality assurance study (REK 617936).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eDuring the period under review, a total of 281 forms were collected and included in this study. However, nine of these forms missed the patient's registration number and were consequently excluded from the study. As a result, 272 forms were finally included in the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eStudent t test and Mann-Whitney rank sum test were used to determine statistically significant differences between groups. All analyses were performed using Statistical Package for the Social Sciences (SPSS, version 26.0, IBM). A p value of 0.05% was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 272 (143 male and 129 female) patients with 272 teeth was included in the study, showing no significant gender difference. The average age of patients seeking emergency treatment was 51.2 years, ranging from 20 to 90 years. The most frequent age group attending an emergency appointment was patients over 65 years, accounting for 29.9% of cases, although no significant differences between the age groups were observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe tooth most commonly requiring emergency treatment was the maxillary right first molar (15.4%), followed by the maxillary left first molar and the mandibular right and left first molars, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of all the teeth involved, 61% were located in the maxilla and 39% in the mandible. Teeth that did not present with any emergency problems included the mandibular lateral incisors and the maxillary left third molar.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePain is the most frequent chief complaint by patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Other symptoms included pain on biting or chewing, pain-related sleep disturbances, pain consuming hot or cold beverages or food, swelling and fever (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The duration of pain experienced by patients varied widely, ranging from 4 hours and 4 years with a mean of 49.1\u0026thinsp;\u0026plusmn;\u0026thinsp;36.9 days. The most frequent day for seeking emergency appointment was on day 3 (13.6%) following onset of pain. More than half the patients (51.1%) sought emergency appointment within one week, 70.6% of patients took contact for emergency treatment within one month, 14.3% of patients waited for 3 months or longer before seeking help (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSymptoms reported by patients as a reason for emergency appointment. Several patients reported more than one symptom.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePain when biting/chewing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInsomnia (due to pain)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eWorsening of pain sensation with hot or cold drinks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA significant portion of the patients, 176 or 64.7%, used one or more types of medications to alleviate pain prior to their emergency appointment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of these patients, 61.4% took one type of medication, 34.7% used two types, and 3.9% combined three different medications. The self-administered medications included over-the-counter analgesics, antibiotics, opioids, among others (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The most commonly used analgesic was paracetamol, utilized by 61.9% of those who took medications. Patients often resorted to taking combination drugs or stronger painkillers, as over-the-counter medications did not provide sufficient pain relief.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of medications used by patients for pain relief.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnalgesics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParacetamol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNSAIDS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIbuprofen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVoltarol (Diclofenac)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisbril (Aspirin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntibiotics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApocillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmoxicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDalacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetronidazol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOpioides\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTramadol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCodaxol (paracetamol with codeine)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParalgin forte (paracetamol with codeine)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePinex forte (paracetamol with codeine)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther medications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImovane (Z-drug hypnotics)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSobril (benzodiazepam)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOnly 156 patients, or 57.4%, were able to accurately localize the pain to a specific tooth (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The majority of these teeth had restorations (61.8%), while only 19.1% presented with carious lesions. The most frequent pulp diagnosis was pulpitis (26.8%), followed by pulp necrosis (25.4%) and previously treated teeth (22.8%). The remaining patients presented with pain from periodontal disease or problems associated with fractured or missing fillings.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe patient demographic information. Recurrent caries on teeth with restorations and prosthodontics was registered as caries.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain localization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle tooth 2\u0026ndash;5 teeth\u003c/p\u003e \u003cp\u003eOne quadrant Two quadrants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e156 (57.4)\u003c/p\u003e \u003cp\u003e33 (12.1)\u003c/p\u003e \u003cp\u003e79 (29.0)\u003c/p\u003e \u003cp\u003e4 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronal status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRestoration\u003c/p\u003e \u003cp\u003eCrown/bridge abutment Caries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e168 (61.8)\u003c/p\u003e \u003cp\u003e55 (20.2)\u003c/p\u003e \u003cp\u003e52 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulp diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulpitis\u003c/p\u003e \u003cp\u003ePulp necrosis Previous root-filled tooth\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (26.8) 69 (25.4) 62 (22.8)\u003c/p\u003e \u003cp\u003e68 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most common emergency treatment plan was pulpotomy (25.4%), followed by medications (20.6%), and root canal instrumentation for necrotic cases (16.9%) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The definitive treatment that the patients received is presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. In total, 170 teeth underwent root canal treatment, and 109 patients returned for a one-year follow-up appointment. Of these, 103 teeth (95%) were evaluated to have had a successful outcome, 2% were considered uncertain, and 3% were classified as failures (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEmergency treatment plan. Since several patients received more than one treatment the total is more than the patient number in the study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency treatment plan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulpotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedications/Drugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoot canal instrumentation (necrotic pulp)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestorative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferral to other specialities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriodontal therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe definitive treatment patients received. Since several patients received more than one treatment, the total is more than the patient number in the study.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefinitive treatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoot canal treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient did not return\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestorative or prosthodontic treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriodontal therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical treatment (hemi-section, root amputation or endodontic surgery)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTreatment outcome for teeth that received root canal treatment.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccessful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncertain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main findings of this study indicated that patients often delayed seeking an emergency dental appointment until experiencing significant pain, which served as the primary motivating factor. Restorative treatments, such as fillings or crowns, do not fully protect against pulpal disease. A notable proportion of cases requiring emergency treatment involved previously root-filled teeth. Additionally, patients across all age groups experienced pain, with first molars being the most commonly problematic teeth.\u003c/p\u003e \u003cp\u003eThe dental pulp, when inflamed, is capable of eliciting extreme pain, reaching the highest scores on pain rating scales [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. On the other hand, a necrotic dental pulp is theoretically incapable of giving rise to pain sensation. Interestingly, this study found nearly equal incidences of pulpitis and pulp necrosis. As the disease progresses within the dental pulp, both vital tissue and necrotic remnants may be found, leading to diagnoses such as partial necrosis or pulp necrobiosis. Additionally, a necrotic pulp can lead to symptomatic apical periodontitis, manifesting as pain during biting and chewing [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The most frequent day for seeking emergency appointment was 3 days which is in agreement with\u003c/p\u003e \u003cp\u003eAnother unexpected finding in this study was the complications associated with previously root filled teeth. A previously root filled tooth can fail due to problems associated with coronal restorations, the root filling itself, root fractures or periodontal problems. With more patients choosing to retain their natural teeth, a rise in retreatments of previously root-filled teeth is expected.\u003c/p\u003e \u003cp\u003eThe quality of root canal treatment is imperative to a successful treatment outcome. Therefore, root canal treatments should adhere to a high standard of care during primary procedures. A study from Norway concerning endodontic treatment needs in general dental practice revealed that 11.6% of cases were related to previously root-filled teeth, a finding that coincides with this study where 9.5% of the planned permanent treatments involved surgical and non-surgical retreatments [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most frequent teeth requiring emergency dental treatment were the first molars. This finding is perhaps expected, as these teeth erupt around the age of six and have been in function for the longest period. On the other hand, the incisors in the lower jaw, which erupt at the same time, exhibit the lowest frequency of emergency cases. This discrepancy suggests that multiple factors influence the frequent occurrence of issues with molars. Possible explanations include differences in anatomical complexity and their position within the oral cavity. A study investigating caries prevalence in permanent dentition noted that teeth with deep and complex fissures were at the highest risk [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, it was found that teeth in the upper jaw were more frequently affected by caries than those in the lower jaw, agreeing with the findings of this study and our previous research [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNo gender differences were observed among patients seeking emergency care, which is consistent with findings from a study by Haug and Marthinussen, indicating that women and men experience similar levels of pain related to pulpal and periapical inflammation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, no specific age group was disproportionately affected, as the age range of patients stretched from 20 to 90 years, suggesting that individuals of all ages experience dental pain and require emergency dental care.\u003c/p\u003e \u003cp\u003eA study on dental emergencies in Finland pointed out that carious lesions and its sequelae were the primary causation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, in this study, most of the affected teeth had undergone some form of previous restorative treatment, with many patients displaying fillings. This highlights that patients who make regular dental visits, unfortunately, may face emergency situations. It highlights the reality that restorative treatments, such as fillings or crowns, do not fully protect against pulpal disease.\u003c/p\u003e \u003cp\u003eIn this study, most commonly used medication to alleviate pain was paracetamol, followed by ibuprofen, a finding similar to our previous study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A surprising observation was the wide variety of drugs used by patients for pain relief, including opioids and antibiotics. This diversity in self-medication underscores the need for more effective analgesics to alleviate dental pain. Our previous study reported that 83% of patients reported insomnia despite taking pain killers [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, the desperation to relieve pain emphasizes the substantial impact of dental pain on oral health-related quality of life. Furthermore, a study on individuals suffering from insomnia demonstrated that sleep disturbances significantly deteriorate their quality of life [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLiving with pain significantly affects individuals' ability to function well both physically and mentally [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Most patients cited pain sensation as their primary reason for seeking emergency treatment, with about 70% experiencing pain severe enough to necessitate medication. Consequently, the goals of emergency dental treatment is to relieve pain, control or prevent infection and enhance patients' well-being and quality of life.\u003c/p\u003e \u003cp\u003eDespite the fact that root canal treatment was performed on patients with preoperative pain and other symptoms, the treatment outcome was largely successful. A favorable prognosis for root canal treatment of teeth presenting for emergency treatment provides grounds for recommending dentists to perform root canal treatment rather than extraction.\u003c/p\u003e \u003cp\u003eOne of the limitations of this study is that the undergraduate clinic treats only adult patients, and as a result, children and dental trauma patients are not represented. Although the patient cohort at the Department of Clinical Dentistry may not be representative of the general population, the patients attending regular dental treatment at educational institutions can be comparable to a large private practice consisting of general practitioners and specialists. Future studies should focus on educating patients about when to seek dental treatment and on discovery of better medications that can alleviate dental pain.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere was no singular diagnostic cause leading patients to seek an emergency appointment, highlighting the necessity of a thorough diagnostic procedure. Over the counter pain medications have little effect on alleviating dental pain, often resulting in desperate measures of self-medication. Restorative treatments, such as fillings or crowns, do not appear to protect against future pulpal disease. The good prognosis of root canal treatment for teeth with acute symptoms supports recommending dentists to attempt root canal treatment rather than opting for tooth extraction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eDeclarations of interest: none\u003c/p\u003e\n\u003cp\u003eThe research protocol was approved by the Regional Committees for Medical and Health Research Ethics West, Norway as a quality assurance study (REK 617936). The authors declare that they have no competing interests. This research is supported by the Department of Clinical Dentistry, The Medical Faculty, University of Bergen, Norway.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHere is the CRediT author statement:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSivakami Rethnam Haug: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; and Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eMargrethe R\u0026oslash;egh: Conceptualization, Formal analysis, Methodology; Investigation, Resources, Validation; Visualization; Writing-Original Draft\u003c/p\u003e\n\u003cp\u003eInge Fristad: Project administration, Resources, Investigation, Supervision, Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Contributing authors information:\u003c/p\u003e\n\u003cp\u003eMargrethe R\u0026oslash;egh\u003c/p\u003e\n\u003cp\u003eDepartment of Clinical Dentistry, The Medical Faculty, University of Bergen\u003c/p\u003e\n\u003cp\u003eEmail address: [email protected]\u003c/p\u003e\n\u003cp\u003eProf. Inge Fristad\u003c/p\u003e\n\u003cp\u003eDepartment of Clinical Dentistry, The Medical Faculty, University of Bergen\u003c/p\u003e\n\u003cp\u003eEmail address: [email protected]\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSindet‐Pedersen S, Petersen, J. K., \u0026amp; G\u0026ouml;tzsche, P. C. Incidence ot pain conditions in dental practice in a Danisin county. Community Dentistry and Oral Epidemiology 1985;13:244-246.\u003c/li\u003e\n\u003cli\u003eShah AC LK, Lee MK, Allareddy V. Outcomes of hospitalizations attributed to periapical abscess from 2000 to 2008: a longitudinal trend analysis. J Endod 2013;39:1104-1110.\u003c/li\u003e\n\u003cli\u003eNils Skaug TIBoAB. Akutte infeksjoner. Nor Tannlegeforen Tid. 2005;115 nr 1:30 - 37.\u003c/li\u003e\n\u003cli\u003eD\u0026oslash;ving M, Handal, T., Galteland, P. Bakterielle odontogene infeksjoner. Tidsskrift for Den norske legeforening 2020;7.\u003c/li\u003e\n\u003cli\u003eJevon P, Abdelrahman, A., Pigadas, N. Management of odontogenic infections and sepsis: an update. British Dental Journal 2020;229:363\u0026ndash;370.\u003c/li\u003e\n\u003cli\u003eClarke J. Toothaches and death. Journal of the history of dentistry 1999;47:11-13.\u003c/li\u003e\n\u003cli\u003eBoyce N. Bills of Mortality: tracking disease in early modern London. The Lancet 2020;395:1186-1187.\u003c/li\u003e\n\u003cli\u003eHaug SR, Marthinussen MC. Acute Dental Pain and Salivary Biomarkers for Stress and Inflammation in Patients with Pulpal or Periapical Inflammation. J Oral Facial Pain Headache 2019;33:227-233.\u003c/li\u003e\n\u003cli\u003eDahlstr\u0026ouml;m L, Lindwall, O., Rystedt, H., Reit, C. \u0026lsquo;Working in the dark\u0026rsquo;: Swedish general dental practitioners on the complexity of root canal treatment. International Endodontic Journal 2017;50:636\u0026ndash;645.\u003c/li\u003e\n\u003cli\u003eDorn SO MR, Feldman MJ, Borden BG. Treatment of the endodontic emergency: a report based on a questionnaire-part I. J Endodont 1977;3:94-100.\u003c/li\u003e\n\u003cli\u003eCarrotte P. Endodontics: Part 3. Treatment of endodontic emergencies. Br Dent J 2004;197:299-305.\u003c/li\u003e\n\u003cli\u003eWigsten E, Kvist T, Jonasson P, EndoReCo, Davidson T. Comparing Quality of Life of Patients Undergoing Root Canal Treatment or Tooth Extraction. J Endod 2020;46:19-28 e11.\u003c/li\u003e\n\u003cli\u003eNeelakantan P, Liu P, Dummer PMH, McGrath C. Oral health\u0026ndash;related quality of life (OHRQoL) before and after endodontic treatment: a systematic review. Clinical Oral Investigations 2020;24:25-36.\u003c/li\u003e\n\u003cli\u003eN\u0026auml;rhi M BL, Pigg M, Fristad I, Haug SR. Acute dental pain I: pulpal and dentinal pain. Nor Tannlegeforen Tid 2016;1:10-18.\u003c/li\u003e\n\u003cli\u003eSundqvist G. Bacteriological studies of necrotic dental pulps. Ume\u0026aring; University; 1976.\u003c/li\u003e\n\u003cli\u003eDebelian G DL, Gerner N.W, Lange E, Pedersen I, Ulstad J, Bj\u0026oslash;rntvedt S, Willumsen T. Endodontisk sykdom hos pasienter som opps\u0026oslash;ker allmentannleger i Norge. Nor Tannlegeforen Tid 2013;123:254-257.\u003c/li\u003e\n\u003cli\u003eDemirci M, Tuncer, S., Yuceokur, A. A. Prevalence of caries on individual tooth surfaces and its distribution by age and gender in university clinic patients. European journal of dentistry 2010;4:270-279.\u003c/li\u003e\n\u003cli\u003eJohnsen I, Bardsen A, Haug SR. Impact of Case Difficulty, Endodontic Mishaps, and Instrumentation Method on Endodontic Treatment Outcome and Quality of Life: A Four-Year Follow-up Study. J Endodont 2023;49:382-389.\u003c/li\u003e\n\u003cli\u003eZilinskaite-Petrauskiene I, Haug SR. A Comparison of Endodontic Treatment Factors, Operator Difficulties, and Perceived Oral Health-related Quality of Life between Elderly and Young Patients. J Endodont 2021;47:1844-1853.\u003c/li\u003e\n\u003cli\u003eWidstr\u0026ouml;m E, Pietil\u0026auml;, I, Nilsson, B. Diagnosis and treatment of dental emergencies in two Finnish cities. Community Dental Health 1990;7:173-178.\u003c/li\u003e\n\u003cli\u003eMcCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey. Am J Ther 2008;15:312-320.\u003c/li\u003e\n\u003cli\u003eNiv D, Kreitler S. Pain and quality of life. Pain Pract 2001;1:150-161.\u003c/li\u003e\n\u003cli\u003eIshak WW, Bagot K, Thomas S, Magakian N, Bedwani D, Larson D, et al. Quality of life in patients suffering from insomnia. Innov Clin Neurosci 2012;9:13-26.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pain, diagnosis, decision making, Pulpotomy, Prognosis, Outcome","lastPublishedDoi":"10.21203/rs.3.rs-4625918/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4625918/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eToothache is a debilitating condition, often with mild to excruciating pain, swelling, eating difficulties and insomnia. This study aims to delineate the profiles of patients seeking emergency dental care, focusing on the diagnosis, treatment, and outcomes following non-surgical root canal treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective cohort study was conducted from 2012 to 2021 at the Section for Endodontics, Department of Clinical Dentistry, University of Bergen, Norway. A total of 281 emergency patient forms were analyzed. Data registered included patient demographics, dental history, chief complaints, medications used, diagnostic results, treatments provided and outcome.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 272 patients (272 teeth) were included in the study. Pain was the predominant complaint (98.5%), where only 57.4% of the patients managed to localize pain to a specific tooth. The mean age of patients was 51.2 years with no significant gender differences. The maxillary right first molar (41.9%) was the most frequent tooth needing treatment. The majority of the patients had experienced pain for three days before they attended the emergency appointment. The most frequently used drug for pain management was paracetamol which was stated to have little effect. Teeth that needed endodontic treatment often had fillings rather than caries. The most frequent diagnoses were pulpitis (26.8%) followed by necrotic pulp (25.2%) and previously root-filled teeth (22.8%). Root canal treatment was performed on 62.5% of the teeth and a success rate of 95% was registered at one-year recall.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThere was no singular diagnostic cause leading patients to seek an emergency appointment, highlighting the necessity of a thorough diagnostic procedure. Over the counter pain medications have little effect on alleviating dental pain, often resulting in desperate measures of self-medication. Restorative treatments, such as fillings or crowns, do not appear to protect against future pulpal disease. The good prognosis of root canal treatment for teeth with acute symptoms supports recommending dentists to attempt root canal treatment rather than opting for tooth extraction.\u003c/p\u003e","manuscriptTitle":"Endodontic Emergency Patients’ Profile and Treatment Outcome – A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-19 20:06:08","doi":"10.21203/rs.3.rs-4625918/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-02T05:36:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-28T02:23:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-28T02:22:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-06-23T15:59:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3ba958d5-003c-4b63-b2a9-4079e6fa7bc7","owner":[],"postedDate":"July 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T16:03:49+00:00","versionOfRecord":{"articleIdentity":"rs-4625918","link":"https://doi.org/10.1186/s12903-024-05338-8","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2024-12-26 15:56:52","publishedOnDateReadable":"December 26th, 2024"},"versionCreatedAt":"2024-07-19 20:06:08","video":"","vorDoi":"10.1186/s12903-024-05338-8","vorDoiUrl":"https://doi.org/10.1186/s12903-024-05338-8","workflowStages":[]},"version":"v1","identity":"rs-4625918","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4625918","identity":"rs-4625918","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}