A Comparison of Pain Levels During Pulpectomy,

Extractions, and Restorative Procedures

William H. Rousseau, DMD, Stephen J. Clark, DMD, Bruce E. Newcomb, DDS, Earl D. Walker, DDS,
Paul D. Eleazer, DDS, MS, and James P. Scheetz, PhD
Most previous studies on pain in endodontics have
focused on pain that occurs after root canal ther-
apy. Very few studies have compared pain during
the root canal procedure with pain occurring dur-
ing other dental procedures. In the present study,
250 patients were queried following dental proce-
dures regarding their pain levels prior to treatment
and their pain levels during the treatment proce-
dure. Of the total number of patients, 150 had a
pulpectomy, 50 patients had a single extraction,
and 50 patients had a single restoration. These
patients reported significantly more pain during
extractions than during root canal therapy. Ninety-
two percent of patients undergoing root canal ther-
apy reported that pain during the procedure was
less than or much less than anticipated. Eighty-
three percent of the patients undergoing root canal
therapy experienced less pain during the treatment
procedure than they experienced prior to the treat-
ment.
Some patients perceive a root canal to be a very painful procedure.
Even patients who regularly have operative dentistry procedures
may be hesitant to consent to root canal therapy. Some may even
elect to have the tooth removed rather than have the endodontic
procedure done. However, in 1984, the American Association of
Endodontists conducted an opinion survey about patients knowl-
edge and opinions of endodontic therapy (1). They found that
respondents who had experienced root canal therapy were 4 to 5
times more likely to describe the treatment as painless, compared
with individuals who had not experienced root canal treatment.
LeClaire et al. (2) found that 96.3% of patients with a history of
previous root canal therapy would be willing to have another root
canal procedure if it were indicated.
Fear of pain during endodontic treatment is usually associated
with the procedure itself, not the posttreatment period (3). Most of
the studies involving endodontic pain have not involved the pain
experienced during the actual endodontic procedure (4, 5). The
purpose of this study was to measure the level of patient discomfort
experienced during pulpectomy and compare this with the levels of
pain experienced during an extraction and a restorative procedure.
MATERIALS AND METHODS
Two hundred fifty patients were questioned before and after
undergoing dental treatment in the University of Louisville Post-
Graduate Clinic. One hundred fifty patients in this group had root
canal therapy initiated by one of three senior endodontic residents.
After the endodontic access was complete, working lengths of the
canals were verified either by radiograph or apex locator. The
canals were then cleaned and shaped using a crown-down tech-
nique with hand and rotary instrumentation. In some of the teeth,
treatment was completed during the same appointment by obtura-
tion of the canals with gutta-percha and sealer. The remaining 100
patients were treated by one of the four residents in the Advanced
Education in General Dentistry program. Fifty patients had a single
extraction. The remaining 50 patients had a single restoration,
either a filling or a crown. Patient ages ranged from 18 to 88 yr.
There were 82 males and 168 females. The treating dentist re-
corded the tooth number, patient gender, age, race, pulp vitality
status, type of anesthetic used, anesthetic injection technique or
techniques used, and whether or not the root canal was obturated
at the initial appointment.
Prior to treatment, the patients recorded their level of preoper-
ative discomfort on a 10-cm visual analog scale. This score was
then converted to a numeric value between 0 and 100. After
treatment, the patients completed another visual analog scale that
ranked the level of pain experienced during treatment, and they
were asked how the level of pain that occurred compared with their
expectations.
The teeth in the pulpectomy group had not been previously
accessed for endodontic treatment. The patients involved in the
study were both scheduled and walk-in emergency patients. The
amount of local anesthetic and type of injection was at the discre-
tion of the treating dentist, as was the decision to obturate the
endodontic cases at the first appointment. The groups treated with
either extraction or root canal therapy contained teeth with vital or
necrotic pulps. The group treated with a crown or filling contained
only teeth with vital pulps.
JOURNAL OF ENDODONTICS Printed in U.S.A.
Copyright 2002 by The American Association of Endodontists VOL. 28, NO. 2, FEBRUARY 2002
108
RESULTS
A one-way ANOVA showed that there was a significant differ-
ence in preoperative pain between the three groups (p .05) (Fig.
1 and Table 1). The extraction group (61.10) had a higher pain
level than the pulpectomy group (46.74). The restorative group
(0.16) had the lowest preoperative pain level.
One-way ANOVA also showed a difference between the groups
in intraoperative pain levels. The mean pain level during pulpec-
tomy (7.73) was significantly less than the level for extraction
(23.98) (Games-Howell, p .01). There was much less difference
between mean pain levels during pulpectomy and mean pain levels
during the operative procedures (4.22). However, the difference
was still statistically significant (Games-Howell, p .01), and the
operative procedures were less painful.
The 250 total patients were evaluated to compare mean pain
levels during treatment using the variables of sex and pulp vitality
status. No significant difference (p .05) was found between
males (82) and females (168) or between teeth with vital (183) or
necrotic pulps (67). Sixty-two percent (92) of the endodontically
treated teeth were vital, compared with 82% (41) for the extraction
group and 100% (50) for the restorative group.
Seventy-six of the 150 endodontically treated teeth were obtu-
rated at the initial appointment. The mean pain levels during
treatment for obturated teeth were 6.50 versus 8.93 for teeth that
were not obturated. The difference was not significant (p .05).
DISCUSSION
Clinical experience tells us that people are afraid of root canal
therapy. Apparently, a large number believe that a root canal is a
very painful experience. Patients reporting to the endodontist for
their first root canal too often believe that it will be a miserable
experience. There is no doubt that some patients can experience
pain associated with root canal therapy, but when does the pain
occur? Patients often report for root canal therapy with significant
preoperative pain. Studies of postoperative pain generally report
that approximately 20% to 40% of patients will have some degree
of posttreatment pain (610).
As this study illustrates, pain during the endodontic procedure
can be controlled. Multiple methods of anesthetic administration
may be necessary to obtain profound anesthesia during treatment.
Patients with an extremely inflamed pulp may experience some
momentary discomfort during treatment. In this study, only 2% of
patients experienced pain during treatment that was worse than
they expected. This could be related to the patients belief that the
procedure will be very painful and their low expectations for
painless treatment.
Extraction patients presented with higher mean pain levels
than endodontic patients, and this could be responsible for the
higher pain levels that occurred during extraction. Another
possible explanation for the lower pain levels during root canal
therapy is a difference in the method of delivery of local
anesthetic. Extraction patients received a block, infiltration, or
periodontal ligament injection or a combination of the three. In
addition to the above three techniques, endodontic patients, if
necessary, were given intraosseous (6), intrapulpal (10), or
Wand injections (3). The quantity of anesthetic used for each
patient was not recorded, but may have been a factor. The
experience of the clinicians could also have been a factor. The
endodontic residents were all in the second year of a 2-yr
program. The general practice residents were in the first year of
a program following graduation from dental school. The addi-
tional experience may have allowed the endodontic residents to
develop better pain management skills.
The reason for the decision to postpone canal obturation on the
endodontic cases was not recorded, but may have been related to
a lack of appointment time, a technically challenging tooth, or
fatigue on the part of the patient or the operator.
There are a number of questions that could be included in future
studies on this topic. It would be interesting to know whether the
patient had previous endodontic treatment on other teeth and their
attitudes or expectations regarding pain prior to treatment. The
amount of anesthetic that was administered could be valuable
information. Finally, basing the decision to obturate on a planned
assignment rather than clinical judgment would be helpful.
The fear of pain during treatment can be a deterrent that pre-
vents patients from seeking treatment or can make them opt for a
treatment that they perceive to be less painful. The fear of pain
during endodontic treatment may influence some patients to avoid
root canal therapy or have a tooth extracted. This study concluded
that this fear is unfounded and that root canal therapy is a less
painful option than extraction. The study also concluded that the
patients symptoms prior to the root canal are usually more painful
than the procedure.
Drs. Rousseau, Newcomb, and Walker are former endodontic residents at
the University of Louisville School of Dentistry, Louisville, KY. Dr. Clark is
assistant professor and director of Undergraduate Endodontics, University of
Louisville School of Dentistry, Louisville, KY. Dr. Eleazer is associate professor
and the director of Postgraduate Endodontics at the University of Louisville,
Louisville, KY. Dr. Scheetz is professor, Department of Diagnostic Sciences,
Prosthodontics, and Restorative Dentistry at the University of Louisville
School of Dentistry, Louisville, KY. Address requests for reprints to: Dr.
Stephen J. Clark, 4910 Crofton Road, Louisville, KY 40207.
TABLE 1. Level of discomfort during treatment
Pain Level Extraction Root Canal Restorative
A lot less than expected 52% 78% 32%
Less than expected 12% 14% 14%
Expected 22% 6% 48%
Worse than expected 8% 2% 6%
A lot worse than expected 6% 0% 0%
FIG. 1. Mean pain scores.
Vol. 28, No. 2, February 2002 Intraoperative Pain 109
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