Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia.n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively.Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before  had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids.Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery. Cesarean delivery is one of the most commonly performed surgical procedures. In 2014, cesarean deliveries accounted for 32% of all births in the United States [Recently, the Procedure Specific Pain Management (PROSPECT) group published guidelines for pain management after elective cesarean delivery performed under neuraxial anesthesia . Pain maThis quality improvement project was performed at Parkland Health and Hospital Systems, Dallas, Texas, after approval from the Institutional Review Board (IRB) of the University of Texas Southwestern Medical Center, Dallas, Texas. A waiver for informed consent was obtained because deidentified patient data were collected from an electronic database.n = 36) and after  implementation of a multimodal opioid-sparing pain management pathway were included. Exclusion criteria included an American Society of Anesthesiologists (ASA) physical status of ≥ 4, history of allergy to local anesthetics, concomitant neuraxial blocks in place, preoperative chronic opioid dependence or history of substance abuse, significant coagulopathies, infection or abnormalities at the TAP block injection sites.The surgical cohort spanned from January 1 through December 31 of 2020. Consecutive patients (age > 16 years) undergoing emergent cesarean delivery under general anesthesia without an epidural before ) and succinylcholine . Maintenance of general anesthesia included nitrous oxide 50% in oxygen and desflurane or sevoflurane. Fentanyl 25–50 µg, IV, boluses were administered to maintain mean arterial blood pressure and/or heart rate within 20% of baseline values. Fentanyl was limited to less than 1 mcg/kg, IV, ideal body weight/hour. Prophylaxis for nausea and vomiting included dexamethasone 8 mg, IV, administered after induction of anesthesia, and ondansetron 4 mg, IV, administrated at the end of the procedure. Hydromorphone 0.2–0.4 mg, IV, was administered, as needed, approximately 20 min prior to the end of the procedure.Prior to the introduction of a multimodal opioid-sparing pain management pathway, patients received morphine via intravenous patient-controlled analgesia (IV-PCA) with inconsistent use of acetaminophen or NSAIDs. As a part of the multimodal opioid-sparing pain management pathway, patients received bilateral ultrasound-guided TAP blocks performed using the classic lateral approach, by an anesthesia attending with significant experience in regional anesthesia at the end of surgery, after skin closure, but before emergence from anesthesia. An ultrasound transducer  was placed transversely on the flank between the anterior superior iliac spine and the costal margin. Using real-time ultrasound imaging, the external oblique, internal oblique and transverse abdominis muscles were identified. After aseptic preparation of the injection site, a 22- gauge 10 cm insulated needle  was introduced anteriorly and in the plane of the ultrasound beam until the tip was seen between the internal oblique and transverse abdominal muscles. Injectate consisted of liposomal bupivacaine 20 mL (266 mg) combined with 20 ml of 0.25% bupivacaine . A total of 20 ml was injected in 5 ml increments with intermittent aspiration into the fascia between the internal oblique and transverse abdominal muscles on each side. Distribution of the injectate between the internal oblique and transverse abdominis muscles was observed under real-time ultrasound imaging.The postoperative multimodal analgesic regimen included ketorolac 30 mg, IV on arrival to the postanesthesia care unit (PACU) followed by 15 mg every 8 h and acetaminophen 1 gm PO or IV scheduled every 8 h. Ibuprofen 600 mg, orally, every 6 h was given starting on postoperative day 2. Pain scores were assessed every 2 h using a verbal numeric rating score (NRS), with 0 = no pain and 10 = worst pain. Rescue analgesics included hydromorphone 0.5 mg, IV boluses every 2 h, as needed, for severe pain (NRS > 7/10). Oxycodone 5 mg, PO, every 4 h as needed, was administered for moderate pain (NRS 4–6/10). Intravenous patient-controlled analgesia (1 mg morphine demand and lockout of 5 min) was allowed if there was significant difficulty managing pain.Data was obtained from electronic medical records by one of the co-authors who was not involved in TAP block placement. This included patient demographics , duration of surgery, and hospital duration. In addition, pain scores using the numeric rating scale (NRS) on arrival in the PACU, and at 2 h, 6 h, 12 h, 48 h, and 72 h after were recorded. Also, opioid consumption at the same time points as pain scores were recorded. Opioid doses were then converted to oral morphine equivalents for normalization [The primary outcome measure was 48-h morphine consumption. Secondary outcome measures included interval postoperative pain scores from the PACU up to 72 h postoperatively. Sample size calculations were based on a previous study involving the use of TAP blocks in patients undergoing open abdominal surgery where the average 48-h morphine requirements were 45 mg with a standard deviation of 10 mg [p < 0.05.Statistical analyses were performed using SPSS software . Continuous data were summarized as mean ± standard deviation for normally distributed variables or as a median (interquartile range), otherwise. Baseline comparisons between the two treatment groups were made using Student’s t-test for demographic data Table  or Mann–p < 0.001), 48, and 72 h, respectively (p < 0.01) (Table p < 0.001) (Table Table p < 0.001) . However, the AFTER-group had a statistically significant reduction in pain scores at the 6 h, 12 h, 24 h and 48 h time points (p < 0.01).Only 2 out of the 36 patients (5.6%) who received a multimodal opioid sparing analgesia required IV-PCA supplementation while 30 out of 36 patients (83.3%) in the BEFORE-group required IV-PCA  or systemic local anesthetic toxicity . The useThe results of this study also demonstrate that a multimodal analgesic regimen is associated with a reduction in the need for IV-PCA opioid administration, thus reducing resource utilization. The use of IV-PCA requires the time for setup, troubleshooting, provider hand-offs and disposal of controlled substances . In addiThe current study has several limitations. One of the limitations of this study is that it is not randomized and lacks blinding as well as contemporary controls. However, clinical quality improvement initiatives provide significant benefits including the ability to evaluate perioperative outcomes in real-world patient settings . AdditioIn conclusion, a multimodal opioid -sparing analgesia regimen is associated with reduced postoperative opioid consumption for cesarean delivery in patients undergoing general anesthesia, and thus should be considered in the absence of neuraxial analgesia.


Pain is a problematic symptom in patients with osteonecrosis of the jaws (ONJ). Effective pain management in patients with advanced ONJ still remains an unresolved issue. This case series report presents three patients who were referred to the pain clinic for treatment of intractable pain caused by ONJ. Two patients received mandibular nerve blocks and achieved pain relief. After referral to the pain clinic, these two patients underwent segmental mandibulectomy for ONJ. In the third patient, the effect of pain control was limited. Appropriate cooperation between the oral and maxillofacial surgeon and the pain specialist is essential for pain management in patients with advanced ONJ who experience intense pain. Osteonecrosis of the jaws (ONJ) is a side-effect of medical treatment such as bone-modifying agents for bone metastasis of cancer or osteoporosis (medication-related osteonecrosis of the jaws (MRONJ)), or radiation therapy for head and neck malignancy (osteoradionecrosis of the jaws (ORNJ)). Both MRONJ and ORNJ cause serious symptoms such as trismus, chronic drainage, disfigurement, and severe pain . These sPain management is an increasingly recognized field because pain-related diseases are the leading cause of disability and disease burden globally . The cooThree patients with intractable mandibular pain caused by ONJ were referred to the department of anesthesiology and pain clinic at our hospital from the department of oral and maxillofacial surgery between July 2016 and April 2021. Clinical characteristics are shown in Table Table Patient 1A 72-year-old female had the right mandibular first molar extracted one year before attending our hospital. Three months after the extraction, she had severe pain in the right mandible and sensory reduction in the area served by the inferior alveolar nerve. She was diagnosed with MRONJ at the former hospital. Pain control by medication was difficult because the patient had severe kidney failure. After experiencing severe trismus, poor nutrition, and dehydration, the patient was admitted as an emergency hospitalization to our hospital. Panoramic x-ray and computed tomographic images showed severe bone destruction in the right mandible without pathological fracture Figure . The patPatient 2An 80-year-old female received radiation therapy for a pharyngeal malignant melanoma eight years before her first visit to our department. She had ORNJ in the right molar region and underwent sequestrectomy via an intraoral approach under general anesthesia eight months after the first visit. After the sequestrectomy, her symptoms, including trismus, persisted. Her chronic pain gradually worsened. Seven months after the sequestrectomy, she was referred to the pain clinic for pain management. The patient received a mandibular nerve block weekly combined with narcotic analgesics. During pain management, a pathological fracture occurred Figure . Three mPatient 3A 66-year-old male received radiation therapy for a right oropharyngeal squamous cell carcinoma and right neck lymph node metastasis eight years before his first visit to our department. He was diagnosed with severe ORNJ in the left mandible. He was followed up with conservative therapy because he had received chemotherapy for hepatocellular carcinoma. Although the mouth opening was only 15 mm during the follow-up, his pain was controlled by acetaminophen and tramadol. Eighteen months after the first visit, the patient was unable to ingest food orally because of the intense pain. Extensive bone destruction in the left mandible was apparent Figure . In the One of the treatment goals for patients with ONJ is the control of pain. Surgery is not indicated for older patients or patients who have problematic comorbidities. Conservative pain management is extremely important. Two of the patients in this case series received continuous or repeated mandibular nerve blocks that succeeded in providing pain relief. Subsequently, both patients (1 and 2) were able to undergo radical extirpation of ONJ while their pain was controlled. In contrast, Patient 3 received a mandibular nerve block only once, because his prognosis was poor.Mandibular nerve blocks are often performed for diagnostic, therapeutic, and anesthetic purposes for mandibular surgery . AdvantaPatient 3 had been diagnosed with ORNJ well over a year previously. He could not receive extirpative surgery for ORNJ because he had received chemotherapy for hepatocellular carcinoma. The timing of the referral to the pain specialist may have been too late to effectively treat this patient’s severe pain. A recent systematic review suggests that specialist palliative case consultations in outpatients have a positive impact on pain control in cancer patients . The EurThree patients were referred to the pain clinic, and received mandibular nerve blocks and narcotic analgesics. Two of the patients underwent surgery for ONJ followed by effective pain management, and one patient was referred to another hospital to receive best supportive care because of an advanced tumor. Appropriate cooperation between oral and maxillofacial surgeons and pain specialists is essential for pain management in patients with advanced ONJ.


The purpose of this case report was to describe chiropractic management of acute lumbar disc herniation in a patient with a large abdominal aortic aneurysm. A 72-year-old male patient presented with low back pain and right lower leg numbness for 12 months. A review of full-spine X-ray and lumbar MRI revealed moderate spondylosis at L2-5, moderate lumbar scoliosis, and a 7.15 cm abdominal aortic aneurysm (AAA). Given the minimum 2-weeks of referral waiting time to receive treatment for AAA, the patient received chiropractic treatment with a hybrid rehabilitation to address the disc herniation causing severe physical disability. Through the treatments, the patient's pain was significantly alleviated with careful consideration of potential risk factors associated with AAA. In addition, the acute disc herniation was successfully managed by a series of chiropractic treatments before and after the operation for AAA. This case supports that low back pain in patients with AAA can be managed by manual therapy, in contrast to a widespread belief that manual therapy is contraindicated in AAA. More case reports of AAA patients with low back pain are warranted to assess the effectiveness and safety of manual therapy along with surgical treatment for AAA. Ultrasound screening studies revealed that 4–8% of the male geriatric population have an occult abdominal aortic aneurysm . Frequen than 55 . AAAs ca than 55 , and app than 55 . The gerSpinal manipulation performed by chiropractic professionals has traditionally been regarded as a red flag in patients with AAA despite the absence of published reports showing its correlation with aortic dissection –8. It ha®), which provided only temporary relief. The patient then sought chiropractic care for conservative management.A 72-year-old Asian male experienced mild right wrist pain, moderate low back pain, and right lower leg numbness for 12 months. The symptoms first started as ache and constant low back pain for 2 years that slowly radiated as episodic right leg numbness for 12 months. As the symptoms had suddenly worsened over the past 2 months, the patient could walk only with a cane. He had difficulties walking for over 15 minutes and more frequent awakening at night due to back pain. The patient had a past medical history of angioplasty and gout 10 years ago, with no known trauma history. The severity of back pain was rated 9/10, which negatively impacted his quality of life and mental health. He was initially diagnosed by the family physician with sciatic pain and received treatment including NSAIDs and celecoxib  was further added to the subsequent treatments to restore nerve dysfunction. The frequency of treatments was reduced to 3 times a week for 3 months.Outcome: Under conservative management, the patient reported 50% relief of musculoskeletal symptoms before the operation. After the operation, the back pain and motor strength started to recover following the second week of post-surgical rehabilitation. The patient continued his treatment once a week, which focused on restoring lumbar disc herniation for an additional 3 months. His sensorimotor dysfunction was mostly resolved after treatment. He was symptom-free and was able to return to normal daily activity. The Oswestry Disability Index was reduced from 68% to 2%. At 12th month follow-up, the patient remained healthy and returned to his weekly hiking hobby. No adverse event was reported.According to the literature study on PubMed, the last chiropractic case report of patients with AAAs was dated 11 years ago, and the published reports are mostly focused on the physical examinations without manual therapy when patients need surgical treatment for AAA , 10–12. Post-surgery care is important for patients with AAA and low back pain. For example, cardiovascular exercise has positive effects in reducing cardiovascular risk and suppression of AAA diameter progression . Given tThis case supports that low back pain in patients with AAA can be managed by conservative treatment options without any complications. More case reports of AAA patients with low back pain are warranted to assess the effectiveness and safety of manual therapy along with surgical treatment for AAA.


Pain catastrophizing and cutaneous allodynia are commonly altered in patients with chronic migraine associated with medication overuse headache (CM-MOH) and tend to improve in parallel with clinical improvement. The relation between pain catastrophizing and cutaneous allodynia is poorly understood in patients with CM-MOH receiving OnabotulinumtoxinA therapy. In this single-arm open-label longitudinal observational study, patients with CM-MOH were assigned to structured withdrawal and then administered OnabotulinumtoxinA . Headache frequency, medication intake, disability, impact, cutaneous allodynia and pain catastrophizing were evaluated with specific questionnaires. In total, 96 patients were enrolled and 79 completed the 12-month follow-up. With the exclusion of cutaneous allodynia and the magnification subscale of the pain catastrophizing questionnaire, all variables showed significant improvement by the sixth month, which was maintained at 12 months. Reduction of pain catastrophizing, and particularly of its helplessness subscale, was a significant predictor of reduction in headache frequency and medication intake. Pain catastrophizing is often implicated in the clinical improvement in patients with CM-MOH receiving behavioral treatments, but, in this study, also showed a role in patients receiving OnabotulinumtoxinA; combining OnabotulinumtoxinA and behavioral treatments specifically addressing pain catastrophizing might further enhance patients’ clinical outcome. Chronic migraine (CM) is a primary headache disorder, a progression of episodic migraine (EM), that is characterized by a headache frequency of fifteen or more headache days/month, of whom at least eight per month exhibit typical migraine features, for at least 3 consecutive months . It is oAs CM-MOH is a condition in which clear biological, psychological and social components are jointly present—i.e., a condition with a biopsychosocial etiology —its treaMigraine-specific prophylaxis may involve both pharmacological and non-pharmacological treatments, the latter basically including neuromodulation, nutraceuticals and behavioral approaches . Among pDifferent hypotheses have been postulated about the mechanism of action of OnabotulinumtoxinA. When OnabotulinumtoxinA is injected, it enters in the cell cytoplasm cleaving the C-terminus of Synaptosomal-Associated Protein, 25 kDa (SNAP-25), which is the target of botulinum neurotoxin type A both in motor nerve and in sensory nerve terminals. This may result in the inhibition in the release of neuropeptides, inflammatory peptides, substance P, glutamate and calcitonin gene-related peptide (CGRP) within the central nervous system, thus playing a therapeutic role in migraine prevention ,19. Its Several factors have been shown to promote migraine “chronification”, or persistent increase, such as metabolic factors, comorbidities, genetic predisposition, lifestyle, medication overuse, and psychological factors ,28,29,30Pain catastrophizing has been shown to have a role in the process of improvement, in particular following behavioral interventions such as mindfulness and acceptance and commitment therapy ,35,36,37The relationship between pain catastrophizing and other variables often implicated in pain experience, such as external locus of control  and cutaneous allodynia , is poorly understood in patients with CM-MOH receiving OnabotulinumtoxinA therapy.With this study, therefore, we aimed to enhance our understanding of the role of allodynia and pain catastrophizing in particular by addressing their improvement in patients receiving OnabotulinumtoxinA according to the PREEMPT protocol  , and by A total of 96 patients were included in the study, 85 (88.5%) were females; mean age was 46.9, SD 9.0, and the mean migraine duration was 28.6 years, SD 9.5. With regard to overused drugs, 40 (41.7%) were triptans over-users only, 16 (16.7%) were analgesics over-users only, and the remaining 40 (41.7%) overused multiple drug classes; additionally, 44 (45.8%) patients showed ASC-12 score ≤ 2, indicative of no allodynia; 29 patients (30.2%) reported headache on a daily basis.A total of 17 patients dropped-out before the study’s completion, so longitudinal analyses were carried out over the records of 79 patients. The results of this study showed that over 12 months, patients with CM associated with MOH who received OnabotulinumtoxinA as prophylaxis according to the PREEMPT study  underwenOnabotulinumtoxinA is one of the most effective and safest among the available preventive treatments for migraine ,15,16,17Patients did not report any significant variation in allodynia scores, as measured by ASC-12 questionnaire, throughout the 12 months of the present study. In previous study in which the ASC-12 was used in patients with CM treated with OnabotulinumtoxinA, a significant ASC-12 decrease was instead observed . HoweverThe role of pain catastrophizing remains an intriguing psychological concern in migraine patients, as well as in those with chronic pain. Pain catastrophizing is strictly related to several pain-related outcomes, including pain expression, disability and mood impairment, as well as with several physiological, cognitive, affective and interpersonal factors associated with pain : thus, iSuch an improvement in pain catastrophizing is of primary clinical relevance, as it is associated with decreased quality of life, and greater use of healthcare services and longer hospital stays in pain-related syndromes ,56. In pSome limitations need to be acknowledged. First, we did not have a control condition, for example another kind of pharmacological prophylaxis: therefore, we cannot entirely disentangle the effect of the specific treatment with OnabotulinumtoxinA from that of the general clinical improvement. The regression models we applied provide justification on the direction of the relation: however, a strict causal relation explaining headache frequency and medication intake reduction cannot exclude OnabotulinumtoxinA treatment which, being an inclusion criterion, cannot be part of the regression models. Second, it was a monocentric study, with the sample being drawn from a third-level specialty center where patients with a considerable disease severity and long history of CM-MOH are expected to attend. Third, in relation to the previous limitation, it has to be taken into account that clinicians working in our center promote patients’ awareness of their mental states and on the correct use of medication. The degree to which such an approach promoted the aforementioned improvement in pain catastrophizing, which had an independent effect on headache frequency and medication intake reduction, cannot be ascertained: however, it cannot be completely ignored. Finally, a note on the possible effects of imputation on the precision of estimates is needed. In fact, the error term that is produced by the imputation is likely lower than the error that would be produced by “real cases”. The implication of this is a possible bias the relations between different variables: this in turn might produce a degree of precision in the imputed values which is higher than warranted, and the predictive power of regression models might be overestimated. However, we think that, considering the trend observed among real cases  and the fact that we imputed only the 12 month values, the overall results of our study would not be significantly different if attrition was smaller. Therefore, we deem that the overall degree of bias can be acceptable. In conclusion, the results of this study show that headache frequency, medication intake and pain catastrophizing improved in patients receiving OnabotulinumtoxinA prophylaxis for CM-MOH. Such an improvement is evident at six months from the inception of the treatment, and is maintained up to 12 months. Moreover, pain catastrophizing, and particularly its helplessness dimension, was predictive for decreased headache frequency and medication intake over 12 months.Learning how to manage headache pain is a process that deals with avoiding catastrophizing in relation to pain. It is reasonable to presume that combining OnabotulinumtoxinA prophylaxis with a behavioral treatment specifically addressing pain catastrophizing might further on enhance patients’ clinical outcome.A longitudinal single-arm open-label retrospective observational study design was implemented. Clinical documentation of patients who met the criteria of the International Classification Headache Disorders, third version (ICHD-3)  for ChroPatients were enrolled at the time they entered a structured in-hospital withdrawal treatment, which was organized in a day hospital regimen for 5 days in order to stop the overuse of symptomatic medications. The main pillars of structured withdrawal included ,59: intrOnce structured withdrawal was completed, patients were administered OnabotulinumtoxinA as prophylaxis following the PREEMPT protocol : 5 sessiMonthly headache frequency, measured with headache diaries, was used as primary endpoint. In addition to headache frequency, diaries included a section on the total intake of symptomatic medications. Both headache frequency and medication intake were evaluated at each OnabotulinumtoxinA administration, i.e., every three months. Other collected data included measures of disability and severity, impact, cutaneous allodynia and catastrophizing attitude: these questionnaires were administered at the baseline, at six and at twelve months.Disability and average headache severity were measured with the Migraine Disability Assessment (MIDAS) . The MIDThe Headache Impact Test (HIT-6)  is a 6-iThe 12-item Allodynia Symptom Checklist (ASC-12)  was usedThe Pain Catastrophizing Scale (PCS)  was usedDue to the important drop-out rates related to COVID-19 pandemics, we operated a missing value imputation for those patients who were lost at the follow-up between the sixth and the twelfth month due to the important limitations in mobility imposed by the pandemic. In fact, almost half of the study participants could did not attend follow-up (45 out of 96), of whom approximately two-thirds (28 of 45 patients) dropped-out between month six and month twelve during the first waves of COVID-19 pandemics in 2020. The last observation carried forward approach was used for missing data imputation. The rationale for this was that our analysis showed that the variation in the herein used endpoints was reported between baseline and six months and, conversely, no change or only minimal changes were observed between six and twelve months.We calculated baseline differences between study completers (including those who were imputed) and drop-out using independent-sample t-test, and longitudinal differences using a repeated-measures ANOVA, with Bonferroni post-hoc analysis. Mauchly’s W test of sphericity was used, and Hyun-Feldt or Greenhouse–Geisser corrections were used when sphericity was violated: the Hyun-Feldt correction was used when Mauchly’s W test was higher than 0.75, and the Greenhouse–Geisser when W was lower than 0.75.p-value ≥ 0.05).Finally, four multivariable linear regression models were implemented to address the predictors of the following: headache frequency change between baseline and six months and between baseline and twelve months; medication intake change between baseline and six months and between baseline and twelve months. Predictors were the respective change, i.e., delta between baseline and six months and delta between baseline and twelve months, in ASC-12, PCS-total and PCS subscales. A backward approach was used, with variables entered together and then excluded if they were not significantly associated to the outcome (i.e., exclusion criterion was Data were analyzed with SPSS 28.0.


Pain management requires a multidisciplinary approach and a collaborative relationship between patient-provider in which communication is crucial. This study examines the communication experiences of Aboriginal and Torres Strait Islander patients and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs), to improve understanding of how pain is managed in and through patient-health professional communication.This qualitative study involved a purposive sample of patients attending three persistent pain clinics and ATSIHLOs working in two hospitals in Queensland, Australia. Focus groups and in-depth interviews explored the communication experiences of patients managing pain and ATSIHLOs supporting patients with pain. This study adopted a descriptive phenomenological methodology, as described by Colaizzi (1978). Relevant statements (patient and ATSIHLOs quotes) about the phenomenon were extracted from the transcripts to formulate meanings. The formulated meanings were subsequently sorted into thematic clusters and then integrated into themes. The themes were then incorporated into a concise description of the phenomenon of communication within pain management. Findings were validated by participants.A total of 21 Aboriginal and Torres Strait Islander participants were involved in this study. Exploration of the communication experiences of patients and ATSIHLOs revealed overlapping themes of important barriers to and enablers of communication that affected access to care while managing pain. Acknowledging historical and cultural factors were particularly important to build trust between patients and health professionals. Some patients reported feeling stigmatized for identifying as Aboriginal and Torres Strait Islander, while others were reluctant to disclose their background for fear of not having the same opportunity for treatment. Differences in the expression of pain and the difficulty to use standard pain measurement scales were identified. Communication was described as more than the content delivered, it is visual and emotional expressed through body language, voice intonation, language and the speed of the conversation.Communication can significantly affect access to pain management services. Aboriginal and Torres Strait Islander patients highlighted the burden of emotional pain caused by historical factors, negative stereotypes and the fear of discrimination. Pain management services and their health professionals need to acknowledge how these factors impact patients trust and care. Pain management aims to control patients’ pain or their responses to pain using multidisciplinary approaches in collaborative relationships with patients, to achieve self-efficacy and improve quality of life . Pain caAmong Aboriginal and Torres Strait Islander people, the burden of musculoskeletal pain conditions is 1.4 times higher than that of the non-Indigenous population. Aboriginal and Torres Strait Islander people are at a higher risk of disabling musculoskeletal pain due to a high prevalence of health, lifestyle and psychological risk factors for pain. These factors result in significant disparities in pain management outcomes , 8. For Ineffective communication is also a major barrier for Aboriginal and Torres Strait Islander people to access health care to manage their pain , 16. A sTo understand the role of communication in detail, this study was designed to examine the communication experiences of Aboriginal and Torres Strait Islander patients managing persistent pain and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLO) who support these patients, aiming to identify how communication affected patients’ pain management and their communication preferences.The present study is part of the first phase of a multi-centre interventional feasibility study to improve communication between health professionals and Aboriginal and Torres Strait Islander patients accessing persistent pain management services in Queensland, Australia. Details of the study protocol have been previously described .The current study reports an analysis of the communication experiences of patients managing pain and of Aboriginal and Torres Strait Islander Hospital Liaison Officers supporting patients managing pain. The findings of the health professionals' perspectives of communication needs and training preferences have been previously published .A purposive sampling approach was used in the study. A service-based researcher  at each study site identified potential participants. One participant group were Aboriginal and Torres Strait Islander patients attending three  of the five publicly-funded adult persistent pain services in Queensland. A second participant group were Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs) working at two study sites .The persistent pain clinics are hospital-based, providing outpatient and inpatient care for people with complex pain who require a multidisciplinary approach to management. According to services audit data, Aboriginal and Torres Strait Islander patients represent between 4%–8% of the total number of patients supported by the three services involved in this study. The ATSIHLOs are Aboriginal and Torres Strait Islander people working in hospitals. Their role is to support and advocate for Aboriginal and Torres Strait Islander patients and/or their families and act as a cultural broker between the patient/their family and health care services.The persistent pain clinics provide tailored care to patients within a biopsychosocial framework. These services aim to rehabilitate and promote self-management. Access to these services depends upon a referral usually from a general practitioner (GP). After patients are referred to the pain clinic, they are assessed according to clinical urgency following the Clinical Prioritisation Criteria (CPC): category 1 (urgent appointment within 30 days), category 2 (appointment within 90 days) and category 3 (appointment within 365 days). The first clinical interaction will involve the patient assessment by a specialist pain physician, sometimes joined by another member of the multidisciplinary team . This interaction may take 1–2 h and options for treatment and pain management will be discussed. A patient may require adjustments to the medication, allied health assessments , group therapy or surgical procedures. Individual management paths vary greatly but at minimum, patients will be supported during a limited timeframe (approximately 12 months) and will be encouraged to take an active role in learning self-management strategies that address their pain.Patients were initially invited to participate in a focus group. For patients who were unable to attend the focus group, in-depth interviews were offered. Patients' and ATSIHLOs data were generated through focus groups or in-depth interviews during the period of October-December 2020. An interview guide was used to ensure the interviews explored the communication experiences of patients managing pain and the experiences of ATSIHLOs working at the study sites supporting these patients. The focus groups were facilitated by an Aboriginal researchers , supported by an Aboriginal research assistant (KH or MT) and two non-Indigenous researchers (CMB and CJ). The in-depth interviews were conducted by two Aboriginal interviewers (MT and KH) and supported by a non-Indigenous researcher (CMB). The focus groups and in-depth interviews were audio-recorded, transcribed verbatim and imported to Microsoft Excel. Separately, the interviewers  used the Microsoft Excel files for analysis.This study adopted a descriptive phenomenological methodology, as described by The research team was composed of researchers from diverse academic disciplines, including medicine, nursing, psychology and physiotherapy. The team includes both, non-clinician researchers (8) and clinicians-researchers (5). The team is also comprised of researchers from diverse cultural and linguistic backgrounds. Five of the authors are of Aboriginal or Torres Strait Islander background and all the remaining authors are non-Indigenous. The research team composition promoted reflexivity across the research process, by including Aboriginal and Torres Strait Islander as well as non-Indigenous perspectives, clinical and non-clinical perspectives, and multidisciplinary perspectives.Although the communication experiences reported here were all related to pain management, these experiences were not limited to persistent pain clinic services. Participants chose to describe their communication experiences across various settings such as emergency departments, general practice appointments, aged-care, or inpatient hospital care.A total of 21 Aboriginal and Torres Strait Islander participants, 13 patients and 8 ATSIHLOs, were involved in this study. Participants were similar in their demographic characteristics.N = 3) and in-depth interviews (N = 10). Patients were more frequently Aboriginal (92%) than Torres Strait Islander, aged on average 49 years (SD = 10.34) and more than half were males (54%) (Patients participated in one focus group (es (54%) . Patientn = 6) and in-depth interviews (N = 2). A high proportion of ATSIHLOs were Aboriginal (87%), on average 51 years (SD = 13.73) and were working on average 9 years (SD = 6.52) in this role.The ATSIHLOs participated in a focus group (the role of ATSIHLOs” and had three subthemes: a) patients are not heard, b) ATSIHLO are the voice, support and empowerment of patients, and c) information credibility. In theme 2, “what is communication”, participants described their perception of communication and had two subthemes: (a) language and delivery of the message, and (b) elements of communication. Theme 3, was clustered around “historical and cultural factors influencing communication” and had three subthemes: (a) cultural factors; (b) historical factors (c) communication preferences; Theme 4, was clustered on “information and literacy” and had two subthemes: (a) sharing good stories and (b) increasing awareness about services. The ATSIHLOs identified that the way information is delivered to Aboriginal and Torres Strait Islander patients can significantly impact their engagement with treatment plans and health services. Patients may disengage from a conversation if the language is too complex, impersonal or perceived as judgemental about the way a person lives their life. Communication between patients and health professionals was described as being very visual, because patients are very attentive to health professionals’ vocal intonation and non-vocal conduct, which is perceived as communicating “emotion”. ATSIHLOs highlighted the importance of health professionals be aware that they sometimes unconsciously or unintentionally give cues that imply judgement about the way people live their lives  [T2].ATSIHLOs reflected on the fact that many patients do not have high literacy levels and consequently have limited understanding of how health services operate and what support they can offer. ATSIHLOs emphasised the importance of promoting the positive results achieved by the pain management services with patients and families to encourage people to seek care. ATSIHLOs recommended that to improve communication between patients and health professionals it is not enough for health professionals be aware of the existence of an ATSIHLO but actually offer this support service to patients. This would help to provide a supportive environment for Aboriginal and Torres Strait Islander patients [T4].Furthermore to provide a supportive environment ATSIHLO mentioned two very strong perceptions related to information and acknowledgement of cultural protocols: the need for acknowledgement of cultural differences and demonstration of respect to cultural protocols ; and patient consent. For example, health professionals should acknowledge to patients that they are aware of the cultural protocol with regards to gender and age group, and in a situation of absence of a health professional of the same gender or age group, confirm with the patients, that they would still be agreeable to proceed with the assessments in this situation. This would demonstrate acknowledgement and respect to cultural protocols [T3].Exploration of the communication experiences of ATSIHLOs revealed the important role these professionals have while supporting patients in managing pain. ATSIHLOs are pivotal in reducing tensions and increasing the trust between the patient-clinician. ATSIHLOs identified that of all Aboriginal and Torres Strait Islander patients, those living with persistent pain would be the most likely to require ATSIHLOs support. Patients in pain experience vulnerability, are unable to advocate for themselves and feel that they are not heard. There is frequently a tension from patients trying to have their pain validated but feeling that health professionals do not believe their experience of pain [T1].Patients managing pain described their experience as of vulnerability, recounting their stories and searching for the cause of their persistent pain. In this search, patients sought for care in several services and communicated with many health professionals. This journey challenged patients to understand how they were approached by health professionals, assessed and supported. Patients confirmed the “broker” role of ATSIHLOs in breaking down communication barriers and linking patients to the service. The simple fact of having the presence of an ATSIHLO gave some patients the assurance of a safer environment [T1].Patients described that their physical pain would sometimes be secondary to family and community commitments and responsibilities. Being in pain affected patients' response to assessments, and sometimes they felt their responses did not align with the expectation of the health professional. This would cause tension, mistrust and a feeling that patients were not heard by health professionals. Patients described feeling emotional pain for being discriminated and stigmatised. This included discrimination on the basis of being an Aboriginal or Torres Strait Islander person. Conversations would change just by the fact that the patient disclosed their background and questions would be directed to issues with drugs and alcohol misuse, and incarceration. For some, it also included discrimination on the basis of not having a stereotypical physical appearance of an Aboriginal or Torres Strait Islander person . Lack of acceptance of patients' Indigeneity, fear of less opportunities for care and a stigma of being seen as a “drug seeker”, combined with the shame of sometimes not disclosing their Aboriginal or Torres Strait Islander background, caused significant emotional pain to patients. Patients' trust that health professionals would help in the management of their pain was increased when patients felt heard. In these situations, patients felt respected and would disclose more details about themselves [T2].Positive communication experiences were reported when the health professional invested more time exploring patients' cultural background and beliefs, recommended alternative treatments  and offered Aboriginal and Torres Strait Islander support services (ATSIHLOs or community services) [T4].In contrast to the positive experiences that were reported, patients perceived that their pain management would be compromised when health professionals would not communicate with them, and would continuously prescribe medication without verifying how the patients were feeling. These health professionals were perceived as “throwing pills on issues” and disregarding the patients' health. This affected patients' ability to physically function, to work and to be active [T5].Factors such as increasing the number of Aboriginal and Torres Strait Islander staff, patient age, health literacy and cultural protocols  should be observed during consultations to improve communication. This was especially relevant to elderly patients living in a more traditional cultural environment, who felt extremely challenged to manage pain and navigate an environment that does not recognize their protocols and customs with regards to age, gender and role in society as an Elder [T6].This study explored patients' and ATSIHLOs' communication experiences across different settings of the healthcare system while managing pain or supporting patients with pain. Although previous studies have explored communication and barriers to management of pain among Aboriginal and Torres Strait Islander patients , 17, thiTrust is built when patients feel that the health professionals know them or that they want to know about them. When health professionals actively listen and learn about the patient, that patient is more likely to trust them. In this context, actively listening often requires understanding the factors underpinning the extent to which Aboriginal and Torres Strait Islanders engage with health services .Patient perceptions of not being heard or believed and consequently feeling that they have ongoing untreated pain with results that were below their expectations are findings shared by other studies amongst non-Indigenous participants living with persistent pain , 27. HowParticular to Aboriginal and Torres Strait Islander patients managing pain is the frustration and emotional pain caused by historical discrimination, stereotypes and stigma. Patients reported enduring emotional pain during some interactions with health professionals and support services. Some of the emotional pain resulted from stereotypes about what the physical appearance of an Aboriginal and Torres Strait Islander person should be. Patients with fair skin reported being questioned and not being accepted as being Aboriginal or Torres Strait Islander. According to Paradies  racism c34With regards to pain, there was a variation of attribution when examining the association between discrimination and outcome (Discrimination or stereotype threat has been found to impair performance by inducing psychological distress, poorer mental health and decreased life satisfaction . Persist outcome . Attribu outcome . FurtherDiscrimination and stereotypes can also affect communication. When the communication between patients and health professionals is not perceived as respectful and pleasant, patient health outcomes will most likely be impacted . An AustIn this study, some patients acknowledged that their fears were unfounded and that they felt empowered by disclosing their background and were fully supported by health professionals.With regards to pain measure, patients in this study reported being locked into a category that would not reflect their individual experience of pain. For Aboriginal and Torres Strait Islander patients historical factors related to colonization, institutionalization and separation contributes to a significant burden of emotional pain making the physical pain sometimes less important  and moreAmong the enablers of communication and improvement in pain management, patients and ATSIHLOs agreed that demonstrating understanding and acknowledging cultural differences and protocols were imperative to establish trust and a collaborative relationship between health professionals and patients. An empathetic and culturally sensitive approach could reduce tension and instigate a conversation about what is relevant to the patient and not be dictated exclusively by a clinical agenda. Most of the participants agreed that when they felt listened to, they could trust the health professional. Respect for some cultural protocols regarding age and gender, e.g., men's and women's business, were mentioned by many patients. Recognising the importance of integrating cultural knowledge and contextualising this to the clinical setting, the current study informs a communication intervention designed to enhance capacity in culturally competent care for Aboriginal and Torres Strait Islander patients with pain .Communication can significantly affect access to pain management services. Although some of the communication experiences in pain management are common to most patients, there are specific issues for Aboriginal and Torres Strait Islander patients. Aboriginal and Torres Strait Islander patients highlighted the burden of emotional pain caused by historical factors, negative stereotypes and the fear of discrimination. Health professionals who provide pain management services need to acknowledge how these factors impact patients and their trust. A model of care that combines greater cultural understanding and fosters trust and respect between patient and health professional could mitigate emotional pain and enable pain management services that are more patient–centred and improve access and effectiveness of service.


Temporomandibular disorders are a common pathology affecting up to 70% of the population, with a maximum incidence in young patients. We used a sample of twenty patients recruited in the Maxillofacial Surgery Service of the University Hospital of Salamanca (Spain), who met the inclusion criteria, with unilateral painful symptomatology of more than three months’ duration. All patients were randomly treated by intramuscular and intra-articular injections of botulinum toxin (100 U) in eight predetermined points. Pain symptomatology was assessed by the visual analog scale (VAS) at the different locations, together with joint symptomatology, at baseline and six weeks after treatment. Adverse effects were also evaluated. In 85% of the patients, pain upon oral opening improved and 90% showed improvement in pain upon mastication. A total of 75% of the patients reported improvement in joint clicking/noise. Headaches improved or disappeared in 70% of the patients treated. Despite the limitations of the study and the preliminary results, intramuscular and intra-articular infiltrations with botulinum toxin were effective in the treatment of symptoms associated with temporomandibular disorders (TMDs), with minimal adverse effects. Temporomandibular disorders (TMDs) is a term that refers to a number of pathological conditions and disorders related to the temporomandibular joint (TMJ) and its associated musculoskeletal structures . This seIt is a common condition, with signs appearing in up to 60–70% of the population, yet only one in four people report the presence of any clinical symptoms, and only 5% of patients seek treatment . AlthougMore than 50% of TMDs manifest as myofascial pain, produced by parafunctional habits, such as clenching or bruxism. Its etiology remains poorly understood, but it is likely to be multifactorial and include anatomical, pathophysiological, psychosocial, environmental, biological, and genetic factors, including pre-disposing, triggering, and perpetuating factors ,7; howevTherefore, multidisciplinary approaches are the ideal treatment option, always with the primary goal of resolving the patient’s pain and dysfunction; a recent systematic review suggested that a multidisciplinary approach involving physical medicine and rehabilitation physicians along with dentists is mandatory for the proper diagnosis and treatment of postural disorders in patients with TMDs. Nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, antiepileptics, and muscle relaxants are the most commonly used drugs in the treatment of acute pain, with NSAIDs being the most commonly used; however, despite the multiple NSAID options available, only naproxen has been shown to be effective in reducing pain . Muscle Clostridium botulinum with forty different serotypes and is one of the most potent toxins. Despite being considered lethal for many centuries, it was the first toxin used in the history of medicine [Botulinum toxin (BTX) is a neurotoxin produced by the anaerobic bacterium medicine . Serotypmedicine .There is a gap in the scientific literature and only a limited number of studies refer to the efficacy of botulinum toxin type A (Botox) and its promising results in the improvement of painful myofascial symptoms ,18,19,20This uncontrolled pilot study analyzed, after six weeks, the efficacy of intra-articular and facial muscle injections of botulinum toxin type A (Botox) on pain and joint clicking/noise associated with temporomandibular joint dysfunction pathology in a sample of twenty patients. Adverse side effects following botulinum toxin injection were also evaluated.A sample of 20 patients (n = 20), who met the inclusion criteria for the study, were recruited at the Maxillofacial Surgery Department of the University Hospital of Salamanca. All patients agreed to participate in the research and signed the informed consent form. This study was conducted in accordance with the Helsinki Declaration and was approved by the Salamanca Health Area Drug Research Ethics Committee on 26 April 2021, Reference CEIm:PI 2021 04 734 and was registered in Clinicaltrials.gov (Identifier: NCT05651256).The study included patients diagnosed with TMDs, according to the established diagnostic criteria , aged be® 100 U, Allergan Pharmaceuticals, Westport, Ireland), kept refrigerated at 5 °C, in 1 mL of sterile saline solution at room temperature. Eight injection sites were marked: three located in the masseter muscle, two in the lateral pterygoid muscle, one in the TMJ and two in the temporalis muscle , before BTX treatment and after six weeks, using the visual analog scale (VAS), in a range from 0 to 10, considering a value of 0 as no pain and 10 as maximum pain.Side effects evaluated included warmth, flushing and hematoma at the injection site, swallowing alteration, contralateral muscle contracture or pain and presence of abnormal jaw movements.The average values of pain intensity, in the different locations, before and after treatment, respectively, are presented in Before treatment, 19 patients (95%) presented with joint clicking/noise, 17 patients (85%) with headaches, 19 patients (95%) with pain upon opening the mouth and 18 (90%) with pain upon chewing.At six weeks after treatment, 75% of the patients reported an improvement in joint clicks/noises. Regarding headaches, 70% showed an improvement/disappearance, and only 1 patient (5%) showed a very slight improvement. Eighty-five percent of the patients showed improvement in pain on headaches and 90% showed improvement in pain on chewing. Pain intensity decreased in all areas injected with BTX; however, three patients (15%) reported minimal or no decrease in pain intensity in the different locations.It is noteworthy that most of the patients did not report having suffered any adverse event after treatment.The most frequent adverse effect was the appearance of abnormal jaw movements, which was present in four patients (20%); however, two patients (10%) reported that these abnormal movements were only present in the first few days after treatment, while two others reported that they continued to suffer them.Two of the patients (10%) reported a sensation of flushing/heat in the injection area in the days following treatment, and only one of the patients (5%) reported the appearance of hematoma in the injected area. Three patients (15%) reported the appearance of muscle contracture/pain on the side contralateral to the injection; however, it is noteworthy that swallowing alteration did not appear in any of the patients .Botulinum toxin has evolved from being a toxicant to a versatile therapeutic tool for a growing list of pathologies; however, treatment with BTX remains controversial and there are not many studies evaluating its efficacy in the treatment of TMDs, most of them being in favor of its use and its ability to alleviate pain associated with this pathology ,28,29,30Freund et al. in 1999  were thePreliminary results of our study found a beneficial effect in 85% of patients with TMDs. These results coincided with those obtained by Sidebottom et al.  who, in The facial areas injected with BTX differ in different studies. Some inject only the masseter muscle , others Although BTX was initially only used in the treatment of focal dystonia, it has been shown to provide relief from migraine and tension headaches and neck pain , suggesting a possible role in the treatment of TMDs ,48,49,50Our study, in accordance with these results, found a disappearance of headaches in 70% of the patients treated, although 15% of the patients reported not having found relief from painful symptomatology. In our study, we combined BTX infiltration in the masseter, temporalis, and pterygoid muscles with intra-articular infiltration, obtaining excellent results on pain in the cervicofacial musculature .On the other hand, intra-articular infiltration of BTX has demonstrated its efficacy in reducing pain . Lora etThe dose ranges are also discrepant in the different studies. Schwartz and Freund recommend doses like those used by us: 25–50 U in the masseter muscle, 5–25 U in the temporalis muscle and 5–25 in the pterygoid muscle . BatifolRegarding adverse effects, Ihde and Konstantinovic, in a review identifying randomized clinical trials evaluating patients treated with botulinum toxin, found that the adverse effects were mild and transient ; similarDespite these results, we are aware of the limitations of the study: on the one hand, the small sample size, although authors such as Sipahi Calis et al. and Patel et al. ,63 base Despite the limitations of the study and presenting preliminary results, we believe that multiple intramuscular and intra-articular infiltrations with BTX-A, with a total dose of 100 U, are effective (at least temporarily) in relieving TMJ pain and clicking and noises, with minimal adverse effects. Future ongoing controlled studies, with a larger sample of patients and longer-term follow-up, will allow comparison of the results.


During non-surgical retreatment process, the products such as dentin debris, root canal fillings, irrigation solutions, microorganisms and remaining pulp tissues can extrude to the apical area and can cause the postoperative pain and flare-up. Thus, the aim of this study was to evaluatethe effect of EDDY and manual dynamic activation (MDA) techniques on postoperative pain (PP) associated with retreatment.n = 45) on the basis of the need for additional irrigation activation procedures (EDDY and MDA). The patients’ post-treatment pain levels were asked to rate the intensity of their pain on a 10-point numerical rating scale (NRS) at the 12th, 24th, 48th, and 72nd h and 7 days.The data were analyzed using the chi-square and Wilcoxon signed-rank test was used for within-group comparisons and Mann Whitney U test was used to compare the groups by time period.Ninety patients scheduled for retreatment were treated at a single visit. Non-vital mandibular premolar teeth diagnosed with asymptomatic apical periodontitis were included in this study. The patients were divided into two groups (p < 0.05). There was no significant difference at 7 days. Moreover, no statistically significant difference was found between the two groups in terms of gender and analgesic medication intake (p > 0.05). Pain intensity after the treatment was lesser in the MDA groupthanin the EDDY group at 12, 24, 48, and 72 h.The difference in postoperative pain intensity between two groups was statistically significant at 12, 24, 48, and 72 h (This study could lead us to conclude that the two activation systems can be used during endodontic retreatment with no difference at PP 7 days later. However, a comparison of the groups indicated that the EDDY resulted in significantly more PP at 12, 24, 48, and 72 h.Trial registration ClinicalTrials.gov Identifier: NCT04726670.The online version contains supplementary material available at 10.1186/s12903-022-02702-4. Success in non-surgical retreatment is the removal of the contaminated previous root canal filling followed by the re-shaping, disinfection and finally hermetic filling of the root canals. Mechanical enlargement is not sufficient for widening and cleaning root canals because of the inability to make contact with all the dentin walls. Chemomechanical preparation is needed for many reasons, such as debris removal, canal disinfection, and lubricant effects during root canal treatment . Nickel–Manual dynamic activation (MDA), passive ultrasonic irrigation (PUI), and sonic irrigation (SI) are the most frequently used activation techniques . In the These activation methods and preparation techniques have been found to cause inflammation in the periapical tissues. A certain amount of debris is extruded from the apical during the preparation for or removal of a root canal filling –10. ThesThe sample size was based on apilot study data that indicated that 38 patients would be sufficient for each group . To compensate for possible dropouts during the treatment and/or follow-up periods, 45 patients were assigned to each group.www.clinicaltrials.gov . Informed consent was obtained from all subjects.Patients referred to the endodontic clinic were asked to complete a questionnaire to provide pre-treatment clinical conditions and demographic data.In this study, Consolidated Standards of Reporting Trials guidelines were followed Fig.  Additio. This doThe sample comprised patients requiring non-surgical retreatment in previously treated mandibular premolar teeth with asymptomaticapical periodontitis.The inclusion criteria were as follows:Healthy individuals between aged 18 and 50 years.Previously root canal treated mandibular premolar teeth with asymptomatic apical periodontitisconfirmed by clinical and radiolographic examination.Single rooted mandibular premolar teeth with single canal that were confirmed by periapical radiographs.Teeth with previous root canal obturation 2–4 mm short of the apex.Periapical radiolucency (PAI 3–4) detected  by radioPresence of intact coronal restoration.Teeth on which root canal treatment had been performed in the researcher’s hospital at least 4 years before the study.The exclusion criteria were as follows:Use of drugs, such as analgesics, anti-inflammatories, and antibiotics, for pain and infection control in the previous 12 h.A history of susceptibility or adverse reactions to any drugs or materials used in the study.Teeth with open apexes and resorption.Teeth with post-core restoration.Vertical root fractures and teeth on which surgery had been performed.Pregnancy and breastfeeding.www.randomizer.org, a free resource for researchers to generate random numbers or randomly assign participants to experimental conditions. Patients were assigned to study groups in accordance with the number sequence obtained on the site.A total of 90 patients were randomly divided into 2 groups, The randomization protocol was implemented on A single clinician performed non-surgical retreatment on each of the 90 teeth during a single visit.A 27-gauge dental injector  was used to anesthetize the patients with a solution of 40 mg Articain and 0.006 mg/mL epinephrine . Old restorations and caries were removed, and on the basis of the straight-line principle, round diamond burs were used to create access cavities under rubber dam isolation. All subsequent treatment procedures were performed under rubber dam isolation, and 3.5× (ZumaxSle Loupe) magnification. When necessary, the cervical margin was elevated with composite resin to ensure the continuity of the isolation.n = 45)  files D1-D3) with an endodontic motor , at 550 rpm and 2.5 Ncm torque for mechanical preparation. No solvent was used.The working length was determined with using a #15 K file  and the ProPexPixi apex locater (DentsplyMaillefer). Periapical radiography confirmed the working length the removal of the canal filling. Root canals were enlarged to the ProTaper Universal F3 (30/0.9) size with an endodontic motor , at 300 rpm and 2 Ncm torque. A lubricant  was used between each file to prevent the rotary files from getting stuck in the root canal. A total of 20 mL 2.5% sodium hypochlorite (NaOCl) irrigation solution  was used for each treatment and irrigation was delivered performed withusing an open-ended 27- gauge irrigation needle. For all teeth, the final irrigation was performed with 5 mL 17% ethylenediaminetetraacetic acid (EDTA)solution  for 1 min. After the non-surgical retreatment procedure, the patients were divided into two groups on the basis of the additional irrigation activation procedures with 6 mL 2.5% NaOCl  A final rinse with 6 mL 2.5% NaOCl was performed after shaping, using a ProTaper Universal F3 gutta-percha  with up and down movements and a 2 mm amplitude at a frequency 100 strokes to as 1 mm short from the working length for 1 min.Second group (EDDY) A 28 mm long polyamide tip with 25.04 size and taper was adapted to TA-200  and operated at 6,000 Hz and, the maximum speed setting [ setting  and it wThe root canals were dried with paper points . The working length was reached usingProTaper Universal F3 gutta-percha  with a tuck-back effect.The gutta-percha was then covered with sealer , and root canal fillings were completedusing the single-cone technique.After the completion of the root canal filling procedures, the residual materials were removed with a heat source. A resin composite  was used for the coronal restorations.Occlusal reduction was performed on all the teeth included in the study.No antibiotics or analgesics were prescribed.The postoperative follow-up and evaluation of the cases were performed by a researcher who had no knowledge of the study groups.A 10-point numerical rating scale (NRS) was introduced to the patients, and they were asked to rate their post-treatment pain by telephone after 12, 24, 48, and 72 h.The antibiotics and analgesics usage were questioned.The patients were appointed for the clinical examination 1 week later.Palpation and percussion sensitivity in the treated teeth was determined on the basis of the patients’ perceptions of pain. All percussion tests were performed by the same operator to ensure standardization.The measurement values were based on the 10-point NRS. The pain scores were placed into the following four categories: 0 = none, 1–3 = mild, 4–6 = moderate, and 7–10 = severe.p < 0.05).IBM SPSS Statistics for Windows, Version 21  was used in the statistical analysis. The categorical variables were analyzed using Pearson’s chi-square test.According to the number of subjects in the eyes, chi-square analysis with Fisher’s exact test and Monte Carlo simulations were used. The Wilcoxon signed-rank test was used for within-group comparisons for the different time periods.To compare between groups, the normality of the data was determined using the Kolmogorov-Smirnov test, and Mann Whitney U tests were performed for comparisons. The significance level for all tests was (p > 0.05)  of the 90 patients included in the study were women; 37 (42%) were male. An examination of the distribution of PP on the basis of gender indicated that there was no statistically significant difference between the groups (p = 0.02). The incidence rate of “mild pain” at the 24th h was the highest: 38% in the second group. The incidence of “no pain” in the first group was 93% (p = 0.0001). The incidence of “mild pain” at 48 h was 29% in the second group (p = 0.004). At 72 h, the incidence of “mild pain” was 22% in the second group. Mild pain was not reported in the first group (p = 0.001).There was no significant difference in the PP values regarding day 7.(p > 0.05). According to the Mann-Whitney U test the second group was found statistically significant than first group all time period .The distribution of PP between the groups and within the groups by time period is summarized in Table Multiple factors may cause post-endodontic pain such as age, gender, tooth type, presence of periapical radiolucency, presence of preoperative pain and occlusal reduction , 17 IntrThe double-blind technique was applied in the present study. The patients and evaluating clinicians were blinded about the administered treatment procedure. In addition, the statistician did not have any information about the group characteristics during the analysis. The groups were identified by assigned numbers. It has been reported that dental configurations, analgesics, and pre-operative pain are the factors related with occurrence of incidence of PP. Thus, to facilitate standardization and objectivity, the patients who has mandibular first premolar teeth treatment has been included in the present study. In addition, they had no pain and did not use analgesics before treatment. Retreatment was performed at a single visit because of the possibility of leakage of the temporary filling materials  and the NaOCl is a widely used irrigation solution because of its antimicrobial and tissue-dissolving effects. It can be used in concentrations of 1 to 5.25%. High concentrations might increase the toxic effects on periradicular tissues  and cause PP. Therefore, in the present study, a 2.5% NaOCl concentration was preferred to obtain the optimum benefits from its antimicrobial effects while minimizing its toxic and PP-inducing effects. The standardization of study protocols can mitigate the effects of intraoperative variables on outcomes.Periapical radiolucency has been found to cause PP lasting two or more days . The reaA meta-analysis study investigated the PP incidence after instrumentation with rotary and reciprocating root canal file systems andstated that the rotary instruments are associated with a lower incidence of PP than reciprocating instruments . RegardiIn both groups in our study, pain was the most intense at the 12th h. It then gradually decreased. A comparison of the groups indicated that EDDY resulted in significantly more postoperative pain at 12, 24, 48, and 72 h. There was no significant difference between the two groups during the first week. Therefore, the null hypothesis was partially rejected. Considering the evaluation within the group, the PP levels in the first group were significantly higher at the 12th h and minimal after the 24th h. In the second group, the pain level further decreased after the 48th h. In the present study, a score of 7 to 10 was considered to represent severe pain, which was characterized as a flare-up , 31. It A review of the literature yielded two in vitro studies on the creation of apical extrusion upon usingEDDY. EDDY was found to cause significantly more apical extrusion than ultrasonic, mechanical, and positive pressure agitation techniques , 36. AydIn the current study, postoperative pain severity was evaluatedafter 12, 24, 48, 72 h sand 7 days with a composite measure of patient-reported and clinician-reported outcomes, that included pain scale and clinical examination in accordance with the recent clinical guidelines . Pain waThe effects of gender on PP are controversial. Some studies have reported more incidence of PP in women, 45. OthThe factors in pain incidence and severity remain unclear. Studies in which pain is assessed have limitations. Thus, the present study aimed to objectively evaluate a subjective experience that might be influenced by individual variability. A limitation of the present study is that a sham was not administered after the treatment to prevent the initial levels of PP from taking analgesic.The value of our work lies in the designand validity of the methodology. Randomized controlled trials represent most scientifically rigorous method of hypothesis testing in evidence-based medicine. Despite that the findings cannot be generalized to allretreatment cases, the findings extend our knowledge and add to a growing body of literature onPP after the use of EDDY and MDA activation techniques in non-surgical retreatment. Future investigations designed as split-mouth studies,are suggested, to eliminate individual variabilities.Pain intensity and frequency after a single non-surgical retreatment session were lesser in the MDA group than the EDDY group in the asymptomatic mandibular premolar teeth. There was no difference in PP within the first week after non-surgical retreatment using these activation systems.Additional file 1: CONSORT 2010 checklist.


A painful or non-painful trigeminal nerve lesion brought on by trauma that exhibits symptoms and/or clinical evidence of trigeminal nerve dysfunction is known as painful post-traumatic trigeminal neuropathy (PTTN). In relation to this, the term post-traumatic persistent dentoalveolar pain (PDAP) is an idiopathic condition of chronic neuropathic origin that manifests as a diagnostic challenge for dental practitioners. Neuropathic pain is defined by the International Association for the Study of Pain (IASP) as "pain initiated or caused by a primary lesion or dysfunction in the nervous system." PDAP is located primarily in the teeth and jaws. This study systematically reviews how likely it is to get painful PTTN if the patient received endodontic therapy and the duration between doing root canal therapy (RCT) and getting PTTN. A systematic review was carried out using key search terms from PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) with English as the only permitted language. There were strict inclusion requirements. The 10 articles that were included showed a prevalence of an endodontic procedure anywhere from three to 48 months following post-endodontic treatment, and it mainly affects females in their mid-40s with no variation regarding the areas, whether it is in the maxilla or mandible. The lack of information about the association between RCT and PTTN led practitioners to make wrong diagnoses, which made the patient unwilling to seek further help. So, in this review, we identified some visible characteristics that can help in that process. Persistent dentoalveolar pain (PDAP) is an idiopathic condition of chronic neuropathic origin that manifests as a diagnostic challenge for dental practitioners . SeveralThe duration of persistent idiopathic facial pain, which includes atypical odontalgia (AO), could last for more than two hours up to three months, despite the absence of neurological defects . PDAP moLevel 1 and level 2 evidence with a low-to-moderate risk of bias were the criteria for the complete peer-reviewed search process, which was available in an online database. All studies in the English language that link human endodontic patients and painful PTTN were included. This includes cohort studies, cross-sectional studies, prospective studies, retrospective studies, and randomized controlled trials. High-quality research on this subject was lacking. The Institutional Review Board of Riyadh Elm University has examined the review (registration number FRP/2020/278/293 (REU)).Each of the following internet databases was searched to find potential studies to include in the systematic review: PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL). Using the terms painful PTTN, PDAP, AO, neuropathic orofacial pain, atypical facial pain, phantom tooth pain, and persistent idiopathic facial pain, we conducted an online literature review search for trigeminal nerve injury. The search was limited to articles in the English language. We looked over the words in the abstract and title fields. References from works that matched the requirements for inclusion as well as those from excellent reviews of the subject were examined.Studies were included if they included information on patients who had received a diagnosis of PTTN in conjunction with RCT, provided information on the diagnostic procedures and standards utilized to identify PTTN following RCT, PTTN or unpleasant sensation in regions supplied by the trigeminal nerve had been diagnosed in a sample, were published between 2009 and 2020, and were human subject studies.Studies were disregarded if they dealt with animal subjects in a laboratory setting or research that is unrelated to the study's topic, were conference and book abstracts and article reviews, were written in languages other than English, or were published prior to 2009.Outcome measuresTable Data collection and analysisUtilizing an electronic database, the references of the papers were collected as represented in Figure Data were extracted and independently validated by the fourth and fifth reviewers from each manuscript that satisfied the inclusion criteria as decided by the first, second, and third reviewers. The database was updated with the first and second reviewers, and the third, fourth, and fifth reviewers verified the correctness of the document. The data for each included article is recorded in Table Study characteristicsOf the 10 articles that were chosen, two (20%) were retrospective clinical trials, four (40%) were retrospective studies, one (10%) was a retrospective observational study, one (10%) was a cohort study that was retrospective and prospective, one (10%) was a prospective cohort study, and one (10%) was a prospective longitudinal cohort study. Each research included anywhere from eight to 1,331 individuals. The mean age ranged from 40 to 55.4 years, and the gender distribution ranged from 31% male to 64% female. The median age of PTTN is 40 years. The prevalence of neuropathic pain in the maxillary arch was reported in just two (20%) of the 10 research, whereas the mandibular arch was mentioned in two (20%) of the 10 studies. The interval between the onset of PTTN and the start of RCT is 3-48 months.Diagnostic tests for PTTNExtraoral examination of the face, head, and neck, periapical radiographic examination, asymmetry examination, tender points, auscultation and palpation of the temporal-mandibular joints, and evaluation of mandibular movements were the clinical examination tests used in our study. During the intraoral examination, the patients' occlusion and any interferences with the root-filled teeth were evaluated. The existence or absence of a swelling, sinus tract, periodontal probing depths, pain to pressure or percussion on the tooth, and integrity of the restoration margin was among the clinical data noted. The most often reported diagnostic procedures (any signs or symptoms emanating from adjacent teeth were examined) were reported in eight (80%) of the 10 included papers. Of the 10 examined studies, only one study (10%) used clinical interviews to determine whether the pain "rarely interrupted sleep" and was "non-responsive to analgesics such as non-steroidal anti-inflammatory medications (NSAIDs)." To check for the presence of tissue hyperesthesia around the painful area, a diagnostic local anesthetic (LA) was used. Two (20%) of the 10 included papers addressed this test; hence, they were included. Cone beam computed tomography (CBCT) was used to assess the likelihood of differentiating between symptomatic apical periodontitis and "atypical odontalgia." One (10%) out of every 10 articles that were included provided an illustration of the Pain Catastrophizing Scale and the short-form McGill Pain Questionnaire (SF-MPQ). Visual analog scale (VAS), a numerical rating scale with anchors ranging from 0 (no pain) to 10 (pain as severe as it may be), and the Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) survey are used to determine who had chronic pain (longer than three months). Both were depicted in two (20%) of the 10 articles that were included: a standardized Oral Health-Related Quality of Life (OHRQoL) survey and an evaluation of tooth sensitivity ). The most common self-reported tool used by people to evaluate disease limitations associated with oral problems is the OHIP-14. It has great reliability and validity and is divided into seven sections: functional limitation, pain, psychological discomfort, physical, psychological, or social disability, and handicap. These assessments were in one (10%) of 10 included articles. The pain intensity level was mentioned in one (10%) of 10 included articles. Computed tomography (CT) for other diagnoses was mentioned in one (20%) of 10 included articles.DiscussionThe initial goal of this comprehensive study was to determine how often a patient develops PTTN after receiving endodontic treatment, secondly the time between the endodontic procedure and diagnosis of PTTN, and finally to educate the public and health practitioners on research methods for the identification of the study. Six of the 10 papers that were included utilized the phrase "atypical odontalgia" as their terminology. Although there are substantial differences in how these terms are employed in different studies, terminology like PTTN is routinely used to refer to all of the included studies.In eight of 10 trials, several clinical examination tests were employed. The extra-intraoral examination was one of them. A clinical examination of the face, head, and neck was performed during the extraoral examination . During the intraoral examination, the patient's occlusion and any interferences with the root-filled teeth were evaluated. The existence or absence of a swelling, sinus tract, periodontal probing depths, pain to pressure or percussion on the tooth, and integrity of the restoration margin were among the clinical data noted. Any symptoms or signals coming from nearby teeth were evaluated and taken into account . A strucA routine physical examination of the cranial nerves, dental and periodontal tissues, the head and neck, and the masticatory apparatus (temporomandibular joints and masticatory/neck muscles) was recommended. The studies made an effort to pinpoint tactile trigger points or locations where pressing triggered excruciating pain that traveled beyond the point of stimulation. The following muscles were examined bilaterally: temporalis, masseter, medial pterygoid, sternocleidomastoid, trapezius, and the suboccipital (as one group). Muscle trigger points were included as part of the assessment of muscle involvement, not to be confused with the tactile trigger areas described for classical trigeminal neuralgia (CTN) and peripheral painful traumatic trigeminal neuropathy (PPTTN) . FollowiAnesthetic Test at the University of Southern California Orofacial Pain and Oral Medicine ClinicTo protect the sore area, cotton rollers and a cheek retractor are used. The sore spot is dried with a piece of 2 cm by 2 cm gauze. The patient's level of discomfort is measured using a 0-10 VAS. Benzocaine 20% gel is topically applied to the sore spot. The patient's pain is recorded on the VAS every three minutes. A LA infiltration or nerve block injection with 2% lidocaine gel is administered to the painful region if the pain alleviation is insufficient. Additionally, after three minutes, the pain level is recorded on the VAS. During a subsequent visit, the test is repeated . The tecA third molar was found to be the most frequent cause of trigeminal nerve damage in 519 (48%) females in their mid-40s according to a study by Van der Cruyssen et al. . The aboRegarding the time between the appearance of PTTN and root canal treatment, the level of non-odontogenic pain after six months or more after root canal treatment was reported to be 34% (95%CI 1.4-5.5) ,25. In cIn the retrospective study by De Poortere et al., the following were the statistically significant connections between various treatment subgroups and PTTN: the primary method of injury n = 9, 31%) was implant surgery, which was followed by third molar extraction (n = 6), facial fractures (n = 4), bilateral sagittal split osteotomy (BSSO) (n = 4), and endodontic therapy (n = 3) . Three t, 31% wasAccording to Nixdorf et al., pain that was present six months after RCT can be categorized into: non-odontogenic: eight patients (seven from referred TMD pain and one from PDAP disorder), mixed: two patients , maxillary teeth compromised 53% of treated teeth, and 89% were posterior teeth . Only woIn a study by Melek et al., orofacial discomfort was reported by the majority of PTTN (66%) and trigeminal neuralgia (TN) patients (80%). Patients with TN experienced pain attacks more frequently (71%) than those with PPTTN (28%), but TN patients were more likely to experience numbness (12%). For both the intermittent and affective pain dimensions, there was greater pain intensity in TN. Patients' oral HRQoL was significantly, but similarly, impacted by PPTTN and TN. Patients with TN experienced a condition burden that was noticeably more severe than those with PPTTN, with clear distinctions in the mobility and self-care domains. There was a tendency for TN patients (54%) to report signs of depression more frequently than PPTTN patients (36%), but clinically significant anxiety was similarly common in both groups (34% to 39%). Both groups' oral and overall health status were closely correlated with anxiety and pain self-efficacy .This review highlights a high-to-moderate level of evidence regarding PTTN after endodontic treatment. It was concluded that the pain was reported after endodontic treatment mostly arising from the non-odontogenic neuropathic origin, which also investigated the relationship between PTTN and RCT. This results in evident symptoms such as persistent pain after the endodontic treatment caused by a variety of incidents, such as impaired endogenous analgesia, pronociceptive pain modulation, and failed endodontic treatment, with more female predominance in their mid-40s. The pain difference between pulpal origin and PTTN will give a large insight for practitioners to properly diagnose PTTN without wasting any more time by doing other procedures that can negatively affect the patient’s tolerance level.