Irreversible pulpitis is an inflammatory condition of the dental pulp, highly painful, and one of the main reasons for seeking emergency dental treatment [
1,
2]. Pain associated with irreversible pulpitis represents more than 45% of the reasons for dental emergency consultation in hospital [
3]. Diagnosis of symptomatic irreversible pulpitis is based on clinical findings such as spontaneous mild to severe pain that remains after removal of the stimulus. The most widely used clinical test is the response to heat or cold sensitivity test. The main etiology of irreversible pulpitis is an infectious lesion due to decay or loss of seal under restorations. After tooth trauma, pulp exposure or cracks can also induce a pulpal inflammatory response [
4]. Recommended emergency care is partial endodontic treatment under local and/or locoregional anesthesia [
5,
6]. The purpose of emergency partial endodontic treatment is to stop the pain of pulpitis by removing a portion of the pulp [
7]. Compared to complete pulpectomy, the pulpotomy procedure results in a lower incidence of post-treatment pain [
8,
9]. Several dressings can be used after emergency pulpotomies, camphorated phenol, eugenol, isotonic saline and cresatin, without contribution for the relief of pain [
7]. Ideally, complete final endodontic treatment is performed in the following 72 h, as 55% of patients experience moderate to severe pain due to pulpotomy [
10,
11]. The dental literature reports major difficulty in achieving adequate anesthesia in the mandible in order to perform partial endodontic treatment, especially for molars [
12,
13]. This results in a very painful care experience for the patient [
14]. Management of this type of emergency is costly for health facilities in terms of equipment and time as pulpotomy is the only emergency treatment recommended [
14]. Patient comfort, cost-saving and rationalization of care time justify the search for an alternative to emergency partial endodontic treatment. A recent systematic review by Shirvani et al. [
15] showed superior intraoperative analgesia for patients with irreversible pulpitis after administration of preemptive nonsteroidal anti-inflammatory drugs. But, to our knowledge, no clinical trial on the use of orally administered corticosteroid for the treatment of dental pulp inflammation has been conducted. In current practice, short-course, orally administered corticotherapy (prednisolone) is used to manage oral pain of inflammatory origin [
16‐
18]. Glucocorticoids, thanks to their anti-inflammatory action, can neutralize the inflammatory mediators [
19]. Pulp inflammation can be treated using this molecule: the efficacy of intraosseous local steroid injection for irreversible pulpitis of mandibular molars has already been demonstrated, but this results in local comorbidities and requires specific materials [
20,
21]. Oral administration of short-course prednisolone is simple and safe but its efficacy to manage pain caused by irreversible pulpitis has not yet been demonstrated. Administration of prednisolone per os has a very high (90%) and rapid (at least 4 h) bioavailability. No difference in efficacy between intravenous and oral administration of this molecule was reported in the case of multiple sclerosis [
22]. This oral treatment could limit comorbidities and technical difficulties associated with intraosseous injection and could make it possible for complete endodontic treatment to be delayed to 72 h later in optimal conditions of analgesia for the patient. Despite the difficulties described concerning partial endodontic treatment, it is very effective in terms of pain reduction and can achieve a success rate of 100%. A noninferiority design was, therefore, chosen to compare the effect of short-course, orally administered corticotherapy with partial endodontic treatment in terms of pain reduction during adult emergency care for irreversible pulpitis in permanent mandibular molars.
Objectives
The primary objective of the trial is to compare the effect on pain of short-course, orally administered corticotherapy versus partial endodontic treatment during adult emergency care for irreversible pulpitis in permanent mandibular molars, 24 h after the emergency visit.
The hypothesis is that short-course, orally administered corticotherapy is noninferior to partial endodontic treatment in terms of analgesic efficacy but superior in terms of number of antalgic drugs taken, number of patients coming back to consultation 72 h later, patient comfort and number of injected anesthetic cartridges when performing endodontic treatment.
The secondary objective consists in comparing, depending on the treatment strategy:
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Patient’s comfort during endodontic treatment measured using the “Iowa Satisfaction with Anesthesia Scale” (ISAS) [
23]
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Number of analgesic drugs (step 1 on the World Health Organization analgesic ladder or step 2, taken after the inclusion visit and over 72 h)
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Difference in pain measured using the Numeric Scale (NS) between the emergency visit and 24 h thereafter
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Kinetics of pain, self-assessed using the NS at 6, 12, 24, 48 and 72 h after the emergency visit
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Number of injected anesthetic cartridges to achieve absence of pain during complete endodontic treatment
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Number of patients returning for complete endodontic treatment