Recent narrative reviews affirm a growing trend toward integrating pharmacological and non-pharmacological strategies across all treatment stages—preoperative, perioperative, and postoperative.
Preoperative Approaches
★ Behavioral management
Mitigating anxiety through clear patient communication, environmental modifications, and rapport-building techniques reduces pain perception.
This “iatrosedative” approach improves both patient experience and analgesic efficacy.
★ Pharmacologic premedication
NSAIDs such as ibuprofen, ketorolac, or diclofenac—alone or in combination with acetaminophen—can significantly decrease intra- and postoperative pain.
Diclofenac shows potential superiority when administered intraligamentarily.
Perioperative Techniques
★ Enhanced anesthesia techniques
Achieving profound anesthesia in settings like mandibular molars or symptomatic irreversible pulpitis may require supplemental injections (e.g., buccal infiltration, intraosseous), higher volumes, or alternative agents such as articaine.
★ Occlusal reduction
Reducing occlusion post-instrumentation notably lowers the incidence of postoperative pain. One randomized trial reported a 40% reduction in moderate-to-severe pain at 12 hours and a 25% reduction at 24 hours.
★ Emergency management
Techniques like incision and drainage and cryotherapy serve as useful interventions for flare-ups or interappointment pain, helping alleviate discomfort and decrease reliance on systemic analgesics.
Postoperative Strategies
★ Analgesic regimen
Multimodal, non-opioid analgesia remains the cornerstone. Combining ibuprofen and acetaminophen is often preferred over opioid-containing formulations, which have not demonstrated superior efficacy and carry higher risks.
★ Holistic recovery support
A narrative review on post-endodontic pain highlights the importance of considering patients’ psychological and emotional well‑being—alongside physical healing—to enhance treatment outcomes and foster trust.
► DENTAL BOOK: Vital Pulp Treatment – A Modern Guide to Pulp Preservation
Emerging and Adjunctive Therapies
★ Novel pharmacologic protocols
A 2025 study introduced the “Gabapentin Pyramid Protocol” as an effective option for persistent post‑endodontic pain, showing promising symptomatic relief.
★ Integrative modalities
Recent reviews emphasize emerging adjuncts such as:
- Platelet‑rich fibrin (PRF)
- Cryotherapy
- Low-level laser therapy (LLLT)
- GABAergic modulation
- In silico drug targeting of inflammatory mediators (e.g., IL‑8) - - Acupuncture and photobiomodulation
While these show potential, many require further clinical validation before routine adoption.
Stage / Key Strategies
★ Preoperative → Behavioral techniques; NSAID and acetaminophen premedication
★ Perioperative → Supplemental anesthesia; occlusal reduction; cryotherapy or I&D for flare-ups
★ Postoperative → Multimodal non-opioid analgesia; holistic patient-centered care
★ Emerging → Gabapentin protocols; LLLT; GABA signaling; PRF; acupuncture; IL-8 targeting
Conclusion
Endodontic pain control demands a multifaceted, patient-tailored approach.
Evidence supports the continued use of behavioral strategies, optimized local anesthesia, NSAID-based analgesia, and procedural adjuncts like occlusal reduction.
Moreover, innovative therapies—including gabapentin protocols, photobiomodulation, and in silico targeting—offer future avenues for enhanced pain relief as research evolves.
References
- Falatah et al. (2023): An integrative narrative on pain management strategies. American Association of Endodontists
- Rosenberg et al. – evidence for occlusal reduction and NSAID/acetaminophen combos
- Maurya et al. (2024): Management of anesthesia failures in mandibular molars
- Algarni (2024): Holistic post‑endodontic pain management
- James (2025): Gabapentin Pyramid Protocol for persistent pain
