Assessment of Regaining Pulp Sensibility in Mature Necrotic Teeth Using a Modified Revascularization Technique with Platelet-rich Fibrin: A Clinical Study.

INTRODUCTION: The aim of the present study was to evaluate the possibility of regaining pulp sensibility in mature necrotic teeth using modified regenerative endodontic procedures by inducing bleeding in root canals and using platelet-rich fibrin (PRF). METHODS: Fifteen patients with necrotic pulp with symptomatic or asymptomatic apical periodontitis were included. At the first visit, the tooth was anesthetized, and an access cavity was performed. Mechanical preparation of root canals was performed using the standardized technique reaching apical canal preparation to K-file size #60-80. Double antibiotic paste was injected into the canal, and the cavity was temporarily sealed using glass ionomer cement. Three weeks from the first visit, regenerative endodontic procedures were performed by inducing bleeding, and a freshly prepared PRF membrane was placed in the canal. White mineral trioxide aggregate was placed directly over the PRF matrix, and the tooth was restored with a glass ionomer cement base and resin composite restoration. The electric pulp test was used to record if the teeth included in the study regained sensibility or not every 3 to 12 months follow-up. Readings at different times were compared as categoric qualitative data using the chi-square test and compared as means and standard deviations using the analysis of variance test. RESULTS: Readings of tooth sensibility revealed a highly significant difference (P < .0001) between baseline and the 12-month follow-up period. CONCLUSIONS: The presence of sensibility is indicative of the formation of vital pulplike tissue. Reestablishing real pulp tissue after regenerative endodontic treatment is debatable and still needs high level of evidence with large-scale investigations.

Regenerative endodontics after front tooth trauma. A case report / Regenerative endodontische Therapie nach Frontzahntrauma. Ein Fallbericht

In the context of tooth trauma, mostly the maxillary central front teeth are involved, whereby their roots are in some cases still in the developing stage (immature). Depending on the type of trauma, a necrosis of the pulp is the consequence or at least foreseeable. In order to preserve such a tooth, an endodontic therapy is inevitable. The disadvantage of conventional endodontic therapy methods of immature teeth (apexification, apexogenesis) is the root growth stop. Alternatively, the regeneration/revascularisation of the dental pulp (RP) was suggested, that allows a further root growth. The aim of this case report is to present the procedure of a RP-therapy and to suggest a step-by-step manual.

Healing of Apical Periodontitis after Nonsurgical Treatment in Patients with Type 2 Diabetes.

INTRODUCTION: The purpose of this prospective study was to compare the success of primary root canal treatment between type 2 diabetic and nondiabetic patients and to investigate the effect of periapical healing on glycated hemoglobin (HbA1c) in type 2 diabetic patients with apical periodontitis. METHODS: Sixty mandibular molars with necrotic pulps and apical radiolucency (size ≥ 2 mm × 2 mm) were included in the study. Based on the HbA1c levels, patients were divided into 2 groups: type 2 diabetic (HbA1c ≥6.5%) and nondiabetic (HbA1c <6.5%). Forty-six teeth were evaluated at the 12-month follow-up time period. The primary outcome measure was the change in apical bone density as determined by the periapical index. RESULTS: Both the diabetic and nondiabetic group depicted a significant reduction in the periapical score after endodontic treatment at the 12-month follow-up (P < .05). Significantly less periapical healing was observed in the diabetic group (43%) compared with the nondiabetic group (80%) at the 12-month follow-up (P < .05). HbA1c levels in the diabetic group increased at each follow-up after endodontic treatment. CONCLUSIONS: Diabetes mellitus may have a negative impact on the outcome of endodontic treatment in terms of periapical healing. Nonsurgical endodontic treatment did not improve HbA1c levels in patients with type 2 diabetes.

Post-instrumentation pain after the use of either Mtwo or the SAF system: a randomized controlled clinical trial.

AIM: This randomized controlled trial compared the incidence of post-instrumentation pain associated with Mtwo rotary NiTi files and the self-adjusting file system following canal shaping and cleaning. METHODOLOGY: Following sample size estimation, a total of 130 patients were randomized into two groups based on selection criteria [group Mtwo and group SAF (self-adjusting file)]. Root canal treatment was carried out in two appointments. The teeth were endodontically treated with the appropriate allotted systems following the similar clinical parameters. Patients were asked to rate the intensity of pre-instrumentation and post-instrumentation pain (at 2, 4, 6, 8, 24, 48 h) using the VAS score. The Kruskal-Wallis test was carried out for the overall comparisons of the two systems. The Friedman test was used to compare between time-points with each system. Subgroup analyses for independent variables (gender, pulp status and diagnosis) used the Mann-Whitney test and Wilcoxon signed ranks test (P < 0.05). RESULTS: No significant difference was found between the two groups with respect to post-instrumentation pain. Teeth with pulpal necrosis had significant pain at 8 h compared with teeth with vital pulps (P = 0.04). Teeth with vital pulps in the SAF group had significantly less post-instrumentation pain compared with those in the Mtwo group at 6 h (P = 0.042). Patients who had teeth with nonvital pulps in the SAF group experienced more post-instrumentation pain at 8 h (P = 0.017) and 24 h (P = 0.005). CONCLUSION: The incidence of post-instrumentation pain at different time intervals in patients undergoing root canal treatment was similar for both the self-adjusting file and Mtwo file systems.

A scoping review of root canal revascularization: relevant aspects for clinical success and tissue formation.

The aim of this scoping study was to evaluate the survival rate and nature of tissue formed inside root canals of human immature permanent teeth with necrotic pulps (NIPT) under root canal revascularization (RCR). The search was performed in SciVerse Scopus®, PubMed/MEDLINE, Web of Science®, BIREME and in the grey literature up to November 2015. The keywords were selected using MeSH terms and DECs. Two independent reviewers scrutinized the records obtained considering specific inclusion criteria. The included studies were evaluated in accordance with a modified Arksey and O' Malley's framework. From 375 studies that were evaluated, 75 were included. A total of 367 NIPT were submitted to RCR, from which only 21 needed further endodontic treatment. The weighted mean follow-up time was 17.6 months. The data were derived mainly from case reports (69%) or small case series (15%). NaOCl [0.5-6%] was applied as the disinfecting solution in almost all studies. Triple antibiotic paste was as effective as Ca(OH)2 as on intracanal medicament. De novo tissue was cementum and poorly mineralized bone positive to bone sialoprotein (BSP) but negative to dentine sialoprotein (DSP). Failures were associated mainly with reinfection of the root canal. The majority of included studies reported a significant increase in both root length and width. However, as most of these data came from case reports, they must be interpreted with care, as most were focused on treatment successes (not failures). Therefore, well-designed randomized controlled trials comparing RCR with available apexification treatments are needed to address this gap in the literature.

Regenerative Characteristics of Apical Papilla-derived Cells from Immature Teeth with Pulpal and Periapical Pathosis.

INTRODUCTION: The purpose of this study was to ascertain the regenerative characteristics of apical papilla-derived cells (APDCs) from immature teeth with pulpal and periapical pathosis and thus to provide proof-of-principle evidence for further regenerative endodontic research. METHODS: Pulpal and periapical pathosis was induced in immature permanent double-rooted premolars of beagles, which were randomly assigned to experimental treatment groups: group AO (n = 14), pulp disruption and access left open; group PS (n = 14), supragingival plaque suspension-soaked cotton pellet was introduced, and access was sealed; and control (n = 7), untreated. The teeth were extracted at 2- and 4-week periods after experimental treatments. APDCs were cultured from the extracted teeth, and their cellular proliferation, differentiation characteristics, and stemness were assessed. The data were statistically analyzed. RESULTS: After 4 weeks of intentional pulpal and periapical pathosis induction period, all teeth in group PS showed features of apical periodontitis with necrotic pulp, and their APDCs showed significantly increased proliferation rate and osteogenic/odontogenic differentiation capabilities (P < .05). The stemness was maintained in all APDCs, although the stem cell population was smaller in group PS at 2-week period when the inflammatory responses were most fulminant (P < .05). CONCLUSIONS: The APDCs from immature teeth retained the regenerative characteristics with the differences according to their pulpal and periapical pathosis. The results of this study partly provide the evidence for regenerative endodontic research.

Tissue characterization following revascularization of immature dog teeth using different disinfection pastes.

Revascularization of immature teeth with necrotic pulps traditionally involves the use of triple antibiotic paste, which may sometimes lead to undesirable complications. The objective of this study was to assess tissue repair in immature dog teeth with apical periodontitis subjected to revascularization, comparing two different pastes used for root canal disinfection. Apical periodontitis was induced in 30 dog premolars. Teeth were randomly divided into three experimental groups: root canals filled with triple antibiotic paste (n = 10); root canals filled with 1% propolis paste (n = 10); and no medication (n = 10). An additional group (n = 10, no intervention) was used as control. After 7 months, the jaws were histologically evaluated for the following variables: newly formed mineralized tissue (present/absent); vital tissue in the canal space (absent/periodontal ligament-like/pulp-like); apical extension of root (present/absent); and severity of inflammatory process (absent/mild/moderate/severe). There were no statistically significant differences among the experimental groups in new mineralized tissue formation and apical root development. The formation of vital tissue in the canal space, in turn, was statistically different between the triple paste and propolis groups: vital tissues were present in all revascularized teeth disinfected with propolis paste (100%), compared to 71% of those disinfected with the triple paste. Severity of inflammatory process was different between the triple paste and no medication groups. The new tissues formed onto canal walls and in the root canal space showed characteristics of cementum and periodontal ligament, respectively. Propolis may have some advantages over the triple paste for the revascularization of immature teeth.

Tissue characterization following revascularization of immature dog teeth using different disinfection pastes

Abstract Revascularization of immature teeth with necrotic pulps traditionally involves the use of triple antibiotic paste, which may sometimes lead to undesirable complications. The objective of this study was to assess tissue repair in immature dog teeth with apical periodontitis subjected to revascularization, comparing two different pastes used for root canal disinfection. Apical periodontitis was induced in 30 dog premolars. Teeth were randomly divided into three experimental groups: root canals filled with triple antibiotic paste (n = 10); root canals filled with 1% propolis paste (n = 10); and no medication (n = 10). An additional group (n = 10, no intervention) was used as control. After 7 months, the jaws were histologically evaluated for the following variables: newly formed mineralized tissue (present/absent); vital tissue in the canal space (absent/periodontal ligament-like/pulp-like); apical extension of root (present/absent); and severity of inflammatory process (absent/mild/moderate/severe). There were no statistically significant differences among the experimental groups in new mineralized tissue formation and apical root development. The formation of vital tissue in the canal space, in turn, was statistically different between the triple paste and propolis groups: vital tissues were present in all revascularized teeth disinfected with propolis paste (100%), compared to 71% of those disinfected with the triple paste. Severity of inflammatory process was different between the triple paste and no medication groups. The new tissues formed onto canal walls and in the root canal space showed characteristics of cementum and periodontal ligament, respectively. Propolis may have some advantages over the triple paste for the revascularization of immature teeth.

Predicting severe pain after root canal therapy in the National Dental PBRN.

Some patients experience severe pain following root canal therapy (RCT) despite advancements in care. We sought to identify factors, which can be measured preoperatively, that predict this negative outcome so that future research may focus on preemptive steps to reduce postoperative pain intensity. Sixty-two practitioners (46 general dentists and 16 endodontists) who are members of the National Dental Practice-Based Research Network enrolled patients receiving RCT for this prospective observational study. Baseline data collected from patients and dentists were obtained before treatment. Severe postoperative pain was defined based on a rating of ≥7 on a scale from 0 (no pain) to 10 (pain as bad as can be) for the worst pain intensity experienced during the preceding week, and this was collected 1 wk after treatment. Multiple logistic regression analyses were used to develop and validate the model. A total of 708 patients were enrolled during a 6-m period. Pain intensity data were collected 1 wk postoperatively from 652 patients (92.1%), with 19.5% (n = 127) reporting severe pain. In multivariable modeling, baseline factors predicting severe postoperative pain included current pain intensity (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07 to 1.25; P = 0.0003), number of days in the past week that the subject was kept from their usual activities due to pain (OR, 1.32; 95% CI, 1.13 to 1.55; P = 0.0005), pain made worse by stress (OR, 2.55; 95% CI, 1.22 to 5.35; P = 0.0130), and a diagnosis of symptomatic apical periodontitis (OR, 1.63; 95% CI, 1.01 to 2.64; P = 0.0452). Among the factors that did not contribute to predicting severe postoperative pain were the dentist's specialty training, the patient's age and sex, the type of tooth, the presence of swelling, or other pulpal and apical endodontic diagnoses. Factors measured preoperatively were found to predict severe postoperative pain following RCT. Practitioners could use this information to better inform patients about RCT outcomes and possibly use different treatment strategies to manage their patients (Clinicaltrials.gov NCT01201681).

Effect of conditioned medium from preameloblasts on regenerative cellular differentiation of the immature teeth with necrotic pulp and apical periodontitis.

INTRODUCTION: The purpose of this study was to investigate the effect of conditioned medium (CM) from murine preameloblasts on the cellular differentiation of mesenchymal stem cells (MSCs) in immature teeth with necrotic pulp and apical periodontitis. METHODS: Pulp necrosis and apical periodontitis were induced in 30 immature permanent double-rooted premolars of 3 beagles and were randomly assigned to the following treatment groups: group CM (n = 10), revascularization treatment was performed using CM from preameloblasts of C57BL/6 mice apical bud cells; group CR (n = 10), conventional revascularization treatment was performed; positive control group (n = 5), left infected; and negative control group (n = 5), untreated. The dogs were followed up for 12 weeks and assessed for treatment outcomes with radiographic and histologic analyses. The effect of the CM on sequential Runx2 and osterix messenger RNA gene expression during the differentiation of MG63 osteoblastlike cells was analyzed with real-time polymerase chain reaction. RESULTS: The overall treatment outcomes were not significantly different between the 2 treatment groups. However, the teeth in the CM group showed significantly more mature apices and a higher degree of hard tissue formation with projections intercalating into the pre-existing root dentin (P < .05). In CM-treated teeth, regenerated pulplike tissue was more frequently observed (P < .05). During differentiation, the CM induced early peak expression of Runx2 followed by sustained osterix overexpression. CONCLUSIONS: CM from preameloblasts rendered a favorable effect in providing a physiologic microenvironment for the differentiation of MSCs after revascularization treatment.

Predictive values of thermal and electrical dental pulp tests: a clinical study.

INTRODUCTION: For a diagnostic test to be useful, it is necessary to determine the probability that the test will provide the correct diagnosis. Therefore, it is necessary to calculate the predictive value of diagnostics. The aim of the present study was to identify the sensitivity, specificity, positive and negative predictive values, accuracy, and reproducibility of thermal and electrical tests of pulp sensitivity. METHODS: The thermal tests studied were the 1, 1, 1, 2-tetrafluoroethane (cold) and hot gutta-percha (hot) tests. For the electrical test, the Analytic Technology Pulp Tester (Analytic Technology, Redmond, WA) was used. A total of 110 teeth were tested: 60 teeth with vital pulp and 50 teeth with necrotic pulps (disease prevalence of 45%). The ideal standard was established by direct pulp inspection. RESULTS: The sensitivities of the diagnostic tests were 0.88 for the cold test, 0.86 for the heat test, and 0.76 for the electrical test, and the specificity was 1.0 for all 3 tests. The negative predictive value was 0.90 for the cold test, 0.89 for the heat test, and 0.83 for the electrical test, and the positive predictive value was 1.0 for all 3 tests. The highest accuracy (0.94) and reproducibility (0.88) were observed for the cold test. CONCLUSIONS: The cold test was the most accurate method for diagnostic testing.

Response to intracanal medication in immature teeth with pulp necrosis: an experimental model in rat molars.

INTRODUCTION: The present study aimed at developing an experimental model in rat molars for evaluating treatment strategies in necrotic immature teeth. METHODS: To define the periods to be adopted in the experimental procedures and to confirm induction of periapical lesions and interruption of root embryogenesis, the left lower first molars of 4-weeks-old Wistar rats underwent pulpectomy and were left open to the oral environment. Comparisons with the right lower first molars (vital teeth) were performed in animals with ages of 7, 10, 13, and 16 weeks. In another group of animals the teeth were left open for 3 weeks, and then interventions for disinfection including the use of an antibiotic paste were carried out. Root formation was then assessed after 3 and 6 weeks on the basis of radiographic and histologic evaluation. RESULTS: Vital teeth showed increase of root length and hard tissue thickness throughout the experimental periods. On the other hand, induction of necrosis arrested root formation. Teeth subjected to disinfection with sodium hypochlorite associated with the triple antibiotic paste showed significant reduction of periapical lesions, gain in root length, and increased wall thickness compared with the control (P < .05). CONCLUSIONS: The root canal disinfection protocol used was able to reduce periapical lesion size and improve root development. The experimental model presented should contribute to studies that aim at improving therapeutic strategies for necrotic immature teeth by using a rat model.

Digital subtraction radiography evaluation of the bone repair process of chronic apical periodontitis after root canal treatment.

AIM: To monitor radiographically the progress of bone repair within chronic periapical lesions after root canal treatment using digital subtraction radiography (DSR). METHODOLOGY: Twelve patients with 17 single-rooted teeth with chronic apical periodontitis associated with an infected necrotic pulp were selected for root canal treatment. Periapical radiographs were taken before treatment (baseline) and immediately post-treatment, 45, 90, 135 and 180 days after treatment. The radiographic protocol included the use of individualized film holders with silicone bite blocks. The six radiographic images were digitized and submitted to digital subtraction using DSR software, resulting in five subtracted images (SI). Quantitative analysis of these SI was performed using Image Tool software to assess pixel value changes, considering a step-wedge as the gold standard and a cut-off value of 128 pixels. The aim was to identify any increase or decrease in mineral density in the region of the periapical lesion. RESULTS: A minor decrease in mineral density at the canal filling session and a significant progressive mineral gain in the following evaluations (P < 0.001) occurred. Pairwise comparison of pixel grey values revealed that only the 180-day follow-up differed significantly from the previous SI. CONCLUSION: Digital subtraction radiography is a useful method for evaluating the progress of bone repair after root canal treatment. Noticeable mineral gain was observed approximately 90 days after root canal filling and definite bone repair after 180 days.

Pain associated with root canal treatment.

AIM: To determine the pain experienced by patients during root canal treatment and to correlate with age and gender, pulpal diagnosis, previous periapical status, dental characteristics and length of treatment. METHODOLOGY: One hundred and seventy-six patients (68 men and 108 women), with ages ranged from 6 to 83 years, were randomly recruited. Patients completed a 10-cm visual analogue scale (VAS) that ranked the level of pain experienced during root canal treatment. RESULTS: The mean pain level during root canal treatment was 1.2 +/- 0.8 in a VAS between 0 and 10. Fifty-four per cent of patients did not experience pain. There were no significant differences in relation to gender or age groups. Mandibular teeth had a significantly (P < 0.05) higher percentage incidence of pain in comparison with maxillary teeth. Pain was absent in 63% of anterior teeth compared with 44% in posterior ones (P < 0.01). Interventions shorter than 45 min resulted in a significantly higher percentage of pain absence (P < 0.05). Root canal treatment was significantly (P < 0.05) more painful in teeth with irreversible pulpitis and acute apical periodontitis compared to the group with necrotic pulps and chronic apical periodontitis (P = 0.049). CONCLUSIONS: Root canal treatment in teeth with irreversible pulpitis and acute apical periodontitis was more painful. Age, tooth type and length of the treatment were factors associated with increased risk for pain experienced during the procedure. Knowledge of pain levels endured by patients will allow dentists to decide when to use supplemental local anaesthesia.

Regenerative potential of dental pulp.

The regenerative potential of dental pulp, particularly in mature teeth, has been considered extremely limited. However, our improved understanding of pulpal inflammation and repair and improved dental materials and technologies make vital pulp therapy a viable alternative to root canal treatment. This article explores our knowledge in this regard and the future potential of saving or even regenerating the pulp as a routine dental procedure.

Regenerative potential of dental pulp.

The regenerative potential of dental pulp, particularly in mature teeth, has been considered extremely limited. However, our improved understanding of pulpal inflammation and repair and improved dental materials and technologies make vital pulp therapy a viable alternative to root canal treatment. This article explores our knowledge in this regard and the future potential of saving or even regenerating the pulp as a routine dental procedure.

Vital signs of the emergency patient with pulpal necrosis and localized acute apical abscess.

Vital signs aid in assessing patient health and the disease severity. The objectives of this study were to determine changes in vital signs of patients with pulpal necrosis (PN) and acute apical abscess (AAA). The vital signs measured at the emergency visit were blood pressure, heart rate, temperature, and lymphadenopathy. Visual analogue scales (VASs) were used to assess (1) pain and (2) malaise. Emergency treatment was rendered. At a subsequent (baseline) visit and with clinical symptoms resolved, systemic vital sign measurements and VASs were repeated. The presence or absence of swelling with vital signs and VASs of pain and swelling were compared. Compared with baseline, data showed no marked elevation in temperature, blood pressure, or lymphadenopathy, regardless of presence or absence of swelling. VAS measurements of pain and malaise did show statistically significant higher numbers at the emergency appointment, indicating a difference from baseline. Swelling versus no swelling did not differ. Vital signs were not impacted by localized AAA, although pain and malaise were greater. Vital signs might not be useful determinants of treatment or pharmacotherapeutic measures with localized AAA.

Influence of pulp vitality on length determination by using the Elements Diagnostic Unit and Apex Locator.

OBJECTIVE: The aim of this study was to compare the influence of the pulp condition (vital or necrotic) on the determination of the root canal length by using a fourth generation electronic apex locator (EAL). STUDY DESIGN: The Elements Diagnostic Unit and Apex Locator was used to measure 143 teeth, totaling 294 canals with different conditions (236 necrotic and 58 vital pulp), for root length. After assessing the root canal and ascertaining the tooth length by using the EAL, the position of the file was confirmed by radiograph. The distance between the file tip and the root end was measured radiographically and was compared with the electronic measurement. RESULTS: Under clinical conditions within an acceptable range lower than 0.5 mm, the concordance between the 2 measurements was 96.6%. This new EAL showed no significant difference (P < or = .05) on accuracy of root canal length determination between vital cases (94.8%) and necrotic cases (97%). CONCLUSION: This device proved to be reliable regardless of the pulpal vitality.

Pulp revascularization of immature dog teeth with apical periodontitis.

This study examined the ability of a collagen solution to aid revascularization of necrotic-infected root canals in immature dog teeth. Sixty immature teeth from 6 dogs were infected, disinfected, and randomized into experimental groups: 1: no further treatment; 2: blood in canal; 3: collagen solution in canal, 4: collagen solution + blood, and 5: negative controls (left for natural development). Uncorrected chi-square analysis of radiographic results showed no statistical differences (p >or= 0.05) between experimental groups regarding healing of radiolucencies but a borderline statistical difference (p = 0.058) for group 1 versus group 4 for radicular thickening. Group 2 showed significantly more apical closure than group 1 (p = 0.03) and a borderline statistical difference (p = 0.051) for group 3 versus group 1. Uncorrected chi-square analysis revealed that there were no statistical differences between experimental groups for histological results. However, some roots in each of groups 1 to 4 (previously infected) showed positive histologic outcomes (thickened walls in 43.9%, apical closure in 54.9%, and new luminal tissue in 29.3%). Revascularization of disinfected immature dog root canal systems is possible.

Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps.

OBJECTIVE: This retrospective study compared differences in preoperative pain and medication use in patients with moderate to severe pain who sought emergency endodontic care for teeth with irreversible pulpitis and for symptomatic teeth with necrotic pulps. STUDY DESIGN: A total of 323 patients seeking emergency endodontic treatment completed questionnaires regarding their biographical information, pain, pain history, and medications. Teeth were tested for vitality, mobility, percussion, and palpation pain. Lymphadenopathy was also evaluated. RESULTS: Patients with irreversible pulpitis waited significantly (P <.05) longer before seeking emergency care (9 days vs 4 days) than patients with symptomatic teeth with necrotic pulps. No differences (P >.05) were found between the groups in terms of analgesic or antibiotic use and pain relief from preoperative narcotic medications. Nonnarcotic analgesics were reported to significantly reduce pain more often in patients with symptomatic teeth with necrotic pulps. There were sex differences in the group of patients with irreversible pulpitis: More women than men were taking analgesic medications and, in the group having symptomatic teeth with necrotic pulps, more men than women reported pain relief from their analgesic medications. CONCLUSION: Patients with irreversible pulpitis wait longer to seek emergency treatment. A majority (81%-83%) of emergency patients with moderate to severe pain will have taken some type of medication(s) to help control their pain, and more women than men with irreversible pulpitis will take an analgesic. By taking their preoperative medication(s), this group of patients will get relief 62% to 65% of the time; furthermore, more men than women with symptomatic teeth with necrotic pulps will experience pain relief.