视觉模拟评分法评估根管治疗术后疼痛程度及疼痛相关因素分析

Postoperative pain assessment by visual analogue scale after root canal therapy and to explore the associated clinical factors

目的探讨临床上根管治疗术后发生疼痛的相关因素,包括年龄、性别、术前诊断、牙位、充填情况、是否超充、是否存在术前疼痛等。方法按受试者入选的先后顺序随机选取2018年7月至2019年4月在汕头大学医学院口腔门诊部行上、下颌磨牙及前磨牙根管治疗的患者140例,其中男63例、女77例,记录其首诊情况。统一采用开髓车针获得入口,根管预备方式统一采用标准技术,完成预备后导入氢氧化钙糊剂消毒根管,并采用玻璃离子暂时封闭开髓口。1周后患者复诊,去除暂封物后采用热牙胶垂直加压充填技术完成根管充填,并拍摄术后根尖X线片。24h后患者复诊,采用视觉模拟评分(VAS)法对术后疼痛进行评估,记录数据并进行单因素相关性分析和多因素Logistic回归综合分析。结果共纳入病例140例,84例(60%)出现根充后不适。其中61例(43.6%)患者报告轻度疼痛,中度疼痛和重度疼痛的患者分别为9例(6.4%)和14例(10%)。无患者出现极重度疼痛。卡方检验显示,术后出现疼痛与性别及牙齿类型无关,但是与诊断即术前牙髓感染状态(χ^2=76.11,P<0.001)及根充效果(χ^2=16.3,P<0.001)有关。多因素Logistic回归分析显示术前没有症状,术后疼痛也会相应减少(OR=0.179,P=0.048);糊剂没有超出,也会降低疼痛的发生程度(OR=0.039,P=0.005);慢性牙髓炎发生术后疼痛症状相对于根尖周炎会轻(OR=0.034,P<0.001),而牙髓坏死相对于根尖周炎会增加术后疼痛表现(OR=4.08,P=0.038)。与超充相比,恰填(OR<0.001,P<0.001)与欠填距离根尖<2mm(OR<0.001,P<0.001)都会减轻术后疼痛表现。结论临床医生在操作中应尽量避免超充,在根管预备过程对根尖区的保护,以及糊剂量的控制对避免根充后疼痛尤为重要。对于牙髓坏死和根尖周炎的患者应做好术后沟通工作。

Objective To assess postoperative pain after endodontic therapy and its association with clinical factors such as gender,age,tooth type,pulpal diagnosis,and preoperative pain,length of obturation and sealer extrusion.Methods The patients,who came to the Clinic of Stomatology,SUMC and received the root canal therapy for molars and premolars from July,2018 to April,2019,were randomly selected by simple random sampling(the order of subjects′ recruitment).There were 140 cases, including 63 males and 77 females.Local Anesthesia(2% Lidocain with 1∶80 000 Epinephrine)was administered.Access cavity was prepared with the help of bur.Canal preparation was completed using standard technique.Access was sealed with sterile dry cotton pellet and restored temporarily with double layer of glass ionomer cement.After one week patients were recalled and access was re-opened,obturation was done using continuous-wave of gutta-percha vertical condensation technique.AH-plus sealer was used. Postoperative radiographs were taken.Patients were recalled after 24 hours and postobturation pain was recorded using visual analogue scale(VAS).Data was recorded and χ^2 test and Logistic regression was used for statistical analysis.Results A total of 140 cases were included and 84 patients(60%)developed postoperative discomfort.61 patients(43.6%)reported mild.9(6.4%)and 14(10%)presented moderate and severe pain,respectively.No patients had extremely severe pain.The χ^2 test showed that postoperative pain was independent of gender and tooth type but correlated with the diagnosis of preoperative pulp infection(χ^2 = 76.11,P<0.001)and obturation(χ^2 = 16.3,P<0.001),as well as the presence of sealer extrusion apical orifice.Multivariate Logistic regression analysis showed that no symptoms before operation and postoperative pain was correspondingly reduced (OR = 0.179,P = 0.048).If the paste was not exceeded,the incidence of postoperative pain was reduced(OR = 0.039,P = 0.005).Chronic pulpitis had less postoperative pain than periapical inflammation(OR = 0.034,P<0.001),while pulp necrosis had more postoperative pain than periapical inflammation(OR =4.080,P =0.038).Compared with overfilling, both adequate filling(OR<0.001,P<0.001)and underfilling <2 mm from the root tip(OR<0.001,P< 0.001)reduced postoperative pain.Conclusions A significant association of obturation with postoperative pain was observed in this study.Therefore,clinician should avoid the sealer extrusion when doing the obturation.For the patients with pulp neurosis and periapical lesions,communication after root canal treatment should be pay more attention to.