Anti-inflammatory drugs prescription in the department of endodontics, university hospital centre of cocody, Abidjan

Introduction

Pain management is the most challenging in dental care. In endodontics, clinical management is provided because patients may experience preoperative pulpal or periapical infections, which are usually inflammatory and can impact postoperative pain.1 Still, successful endodontic treatment is the reference treatment to define the inflammation and put an end to the related-pain. According to the National College of Odonto-Conservative Teachers (NCOCT), endodontic treatment is a therapeutic process for root canals in regards to the classic endodontic triad: preparation, antisepsis and obturation. It goes from the coronary end to the apical end of a root canal of a tooth or a dental root according to the High Authority of Health (HAH). However, it is not sufficient on its own to overcome the pain. Thus, drug prescription remains the only available option for relieving pulpal and periapical inflammation pain related.2, 3

In endodontics, anti-inflammatory drugs (steroidal anti-inflammatory and non-steroidal anti-inflammatory drugs) administration can be either systemic or topical.4 Topically, they are introduced into the root canal system for instant relief of acute pain. However, using them can cause allergy, sensitivity and resistance, thus, their use is relatively rare. When they are used systemically, it is for treating inflammatory inflammation and relieving inflammatory pain.5 They are also prescribed for preventive purposes and their analgesic properties in cases of inferior alveolar nerve damage, resulting from either over-instrumentation of the apical nerve not respecting the working length, or by exceedence filling material.6

That is why anti-inflammatory substances can help with inflammatory responses.

However, like any other drug, they have indications and contraindications. With that in mind, the Francophone Society of Dental Medicine and Dental Surgery had recommended that non-steroidal anti-inflammatory drugs be considered only as analgesics because they do not have known side effects and contraindications on edema.⁷ Using anti-inflammatory drugs requires increased vigilance and a good knowledge of their mechanisms, beneficial and adverse effects and incompatibilities.

The objective of this work was to assess the practitioners’ prescription patterns of anti-inflammatory drugs in endodontics at the University Hospital of Cocody, Abidjan, according to the different pulp pathologies and the obturation quality.

Materials and Methods

A descriptive retrospective study was carried out at the Department of Endodontics, University Hospital of Cocody-Abidjan, which focused on analyzing medical records of patients who had been at the Endodontics Department between January 2015 and December 2017. The National College of Dental Surgeons of Côte d’Ivoire (NCDSCI) ethics committee approved the study (NCDSCI/2014/05)).

From 350 reviewed records, were selected for the study sample those that met the following inclusion criteria:

In all, 100 patients’ medical records were selected to assess the endodontic treatment quality from radiographs and anti-inflammatory drug prescriptions. The data collected was processed with Epi-Info.Fr Version 7 and tables and graphs were produced using Microsoft Excel 2016 software.

Results

Results of the processed data are presented in form of tables:

Discussion

According to Aldous JA.et al. and Mickel AK.et al. pain treatment is an inevitable sequence of dental care. 7, 8

Thus, analyzing the 100 medical records has revealed, during that period, an increased frequency of acute pulpitis (25% of cases) (Table 1) than any other pulp pathology. Such a trend in Côte d'Ivoire could be because pain is the main cause of going to the dentist. 9 It was the same scenario at the Conservative Dentistry and Endodontics Clinic in Dakar according to the findings of Kane et al., who had reported a high prevalence of acute pulpitis when assessing the drug intake and prescription patterns. 10

Moreover, this study had shown that they are even higher after initial treatment, particularly in cases of acute pulpitis (35.2%) (Table 4), in contrast to the study by Kane et al. which showed an insignificant number of anti-inflammatory prescriptions after initial treatment. 10 However, in post-obturation, the surveyed dentists had prescribed anti-inflammatory drugs more than TBAs and analgesics and they were mostly in cases of acute pulpitis (42.7%). Indeed, anti-inflammatory drugs prescription between sessions are intended to manage pretreatment pain or prevent potential pain occurrence before the next appointment. They were prescribed after the extirpation of the pulpal parenchyma. This study showed that non-steroidal anti-inflammatory drugs (71%) were the most prescribed, in contrast to Mickel AK et al.’s which reported only 33% after initial treatment.11 Among the prescribed NSAIDs, Ibuprofen® was the molecule of choice (36.62%) after initial treatment (Table 6), which Moore PA et al. said is the most common peripheral analgesic in post-emergency treatment.12 Thus, Ibuprofen® appears to be better tolerated and the one with the most favorable risk/benefit balance of all the NSAIDs chosen in dentistry. It is thus prescribed as first-line.

According to G. Romieu et al., only an accurate diagnosis along with an emergency procedure, whether or not associated with a prescription, can determine initial treatment effectiveness. 13 They believe that emergency treatments should only be implemented if there is no contraindication on the overall, otherwise they are withheld or referred.

However, this study’s findings show that anti-inflammatory drugs were administered very often (71%) both systemically and topically (Table 4) even after the initial treatment. Ideally, anti-inflammatory drugs should be prescribed either topically or systemically after initial treatment. This shows how anti-inflammatory prescriptions were misused in 71% of the cases.

Whatever the diagnosis, endodontic treatment was chosen. Post-obturation X-ray analysis shows that 84% of the fillings were correct versus only 16% characterized by excessive extrusion of filling material in the periapex. In this study, anti-inflammatory drugs were prescribed in 13 cases (45%) although the apical limits of the fillings were normal (Table 7, Table 8). Masson E et al. 14 “on the evaluation of endodontic therapeutics” had the same finding showing 16.6% of fillings with excessive extrusion of filling material in the periapex. Such foraminal crossing is inevitable because the canal is to be cleaned and sealed up to the foramen. However, it should be noted that the assessment criteria of the quality of the fillings vary according to the studies. For example, Barrieshi-Nusair KM. et al. believe in considering the length of the fillings to assess their quality, while Matysiak M. et al. considered not only the length but also the density of the root canal filling.15, 16 As for Unal GC. et al, the apical limit of the filling at ≤ 2 mm from the radiographic apex was considered as the standard for assessment and others have even added the conicity.17

In any case, incomplete obturation can hinder over 20% of a treatment success rate (L. Tronstad) and it thus appears as the factor having the most negative impact on the prognosis.18 Indeed, endodontic sealing is supposed to contend fluids percolation but also endodontic-periodontal bacterial percolation. Although it is impossible to determine by radiograph the true degree of sealing of a completely sealed canal, parameters indicating insufficient or absent sealing are nevertheless very visible: presence or absence of a radio-opaque filling, lack of standardization of the sealing, presence or absence of radiolucency bordering the filling. 14 Thus, to overcome these endodontic treatment limitations and requirements, prescribing anti-inflammatory drugs is necessary. According to Descroix V., NSAIDs are the common endodontics post-operative prescription in the case of excessive extrusion of filling material in the periapex, by this study results (16 cases recorded), (Table 7). 19 Ibuprofen® was the most prescribed molecule after root canal filling (Table 8) because it blocks both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) enzymes. Furthermore, it is safe and cost-effective with a very effective analgesic and anti-inflammatory action for post-endodontic pain treatment.20

Conclusion

In Côte d'Ivoire, pain is the main reason for consulting the endodontic service.9

Patient management is often preceded and/or followed by anti-inflammatory drugs prescription for relief. Prescribing anti-inflammatory drugs is common, rightly or wrongly, even after an adequate root canal treatment. However, there is still a significant gap between the level of knowledge and their clinical application possibilities. This, sometimes, leads to erroneous, insufficient, or even imprecise prescriptions, or the risk of adverse effects outweighs the benefit to the patient.

In any case, the choice of an anti-inflammatory should take into account not only the diagnosis made but also and above all the desired effect. This requires a proper and controlled approach from the practitioner to anticipate the risks of harmful side effects to the patient.

Source of Funding

No financial support was received for the work within this manuscript.

Conflict of Interest

The authors declare they have no conflict of interest.