Pain management in acute apical abscesses with valacyclovir monotherapy after emergency chamber opening: a prospective randomized clinical study

Background: Acute apical abscesses represent a prevalent dental emergency characterized by severe pain and localized inflammation resulting from bacterial infection within the endodontic system. While conventional treatments focus on emergency chamber opening, there is growing interest in exploring adjunctive therapies to improve pain management and reduce the risk of recurrence. This randomized clinical trial aimed to evaluate the efficacy of valacyclovir monotherapy in alleviating postoperative pain and reducing the risk of recurrent infection following emergency chamber opening for acute apical abscesses. Methods: Eighty-two patients presented with clinical indications of pulp necrosis and acute apical abscesses underwent an emergency chamber opening and pulpectomy. Subsequently, these patients were randomly and equally assigned to receive either valacyclovir monotherapy (Group A) or standard treatment (Group B). Pain levels were assessed using the Numeric Rating Scale (NRS-11), and analgesic consumption was recorded daily for six days. Statistical analysis was performed to compare pain scores and analgesic intake between the two groups. Results: Valacyclovir monotherapy did not demonstrate a significant difference in pain scores compared to standard treatment over the six-day assessment period. Although pain scores varied between the groups, differences were not significant on most days. However, Group A had a slightly higher mean pain score on Day 4, which was statistically significant. Conclusions: The findings suggest that valacyclovir monotherapy may not provide substantial pain relief following emergency chamber opening for acute apical abscesses. Future research may explore alternative treatment approaches or combination therapies to enhance pain management and improve clinical outcomes in this patient population. Clinical Trial Registration: NCT06344195.

Pain management; Acute apical abscesses; Endodontics; Dental emergency; Valacyclovir monotherapy

[1] Abdullah FM, Hatim QY, Oraibi AI, Alsafar TH, Alsandook TA, Lutfi W, et al. Antimicrobial management of dental infections: updated review. Medicine. 2024; 103: e38630.

[2] Ramadan A, Abdel-Monem MO, El-Dougdoug NK, Mekky AE, Elaskary SA, Al-Askar AA, et al. Fully characterized effective bacteriophages specific against antibiotic-resistant Enterococcus Faecalis, the causative agent of dental abscess. Medicina. 2024; 60: 501.

[3] Pucci R, Cassoni A, Di Carlo D, Bartolucci P, Della Monaca M, Barbera G, et al. Odontogenic-related head and neck infections: from abscess to mediastinitis: our experience, limits, and perspectives—a 5-year survey. International Journal of Environmental Research and Public Health. 2023; 20: 3469.

[4] Hargreaves KM, Goodis HE, Tay FR. Seltzer and Bender’s dental pulp. 2nd edn. Quintessence publishing company: Batavia. 2012.

[5] Cope AL, Francis N, Wood F, Thompson W, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database of Systematic Reviews. 2024; 5: CD010136.

[6] Kaushik A, Rana N, Ashawat MS, Ankalgi A, Sharma A. Alternatives to β-lactams as agents for the management of dentoalveolar abscess. Current Topics in Medicinal Chemistry. 2024; 24: 1870–1882.

[7] Mahmood MK, Fatih MT, Kurda HA, Mahmood NK, Shareef FU, Faraidun H, et al. Role of viruses in periodontitis: an extensive review of herpesviruses, human immunodeficiency virus, coronavirus-19, papillomavirus and hepatitis viruses. World Journal of Virology. 2024; 13: 99070.

[8] Rotstein I, Katz J. Acute periapical abscesses in patients with herpes simplex type 1 and herpes zoster. Journal of Oral Medicine & Oral Surgery. 2022; 28: 45.

[9] Siqueira JF III, Rôças IN. Polymerase chain reaction-based analysis of microorganisms associated with failed endodontic treatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2004; 97: 85–94.

[10] Germack M, Sedgley CM, Sabbah W, Whitten B. Antibiotic use in 2016 by members of the American Association of Endodontists: report of a national survey. Journal of Endodontics. 2017; 43: 1615–1622.

[11] Isola G. Antibiotics and antimicrobials for treatment of the oral microbiota: myths and facts in research and clinical practice. Antibiotics. 2020; 9: 95.

[12] Méndez-Millán JA, León-López M, Martín-González J, Saúco-Márquez JJ, Cabanillas-Balsera D, Segura-Egea JJ. Antibiotic over-prescription by dentists in the treatment of apical periodontitis: a systematic review and meta-analysis. Antibiotics. 2024; 13: 289.

[13] Esteve-Pardo G, Barreiro-Gabeiras P, Esteve-Colomina L. Pulpectomy vs. pulpotomy as alternative emergency treatments for symptomatic irreversible pulpitis—a multicenter comparative randomised clinical trial on patient perceptions. Clinics and Practice. 2023; 13: 898–913.

[14] Crimi S, Fiorillo L, Bianchi A, D’Amico C, Amoroso G, Gorassini F, et al. Herpes virus, oral clinical signs and QoL: systematic review of recent data. Viruses. 2019; 11: 463.

[15] Majewska A, Mlynarczyk-Bonikowska B. 40 years after the registration of acyclovir: do we need new anti-herpetic drugs? International Journal of Molecular Sciences. 2022; 23: 3431.

[16] Tahmasebi E, Keshvad A, Alam M, Abbasi K, Rahimi S, Nouri F, et al. Current infections of the orofacial region: treatment, diagnosis, and epidemiology. Life. 2023; 13: 269.

[17] Alsharqawi NS, Austah ON. Single-visit regenerative endodontic procedure of necrotic immature lower permanent molar with acute apical abscess. Saudi Endodontic Journal. 2023; 13: 204–210.

[18] Sabeti M, Zhong J, Hildebrandt K, Slots J. Valacyclovir in pain management of acute apical abscesses: a randomized placebo-controlled double-blind pilot study. Journal of Endodontics. 2021; 47: 1724–1728.

[19] Li H, Chen V, Chen Y, Baumgartner JC, Machida CA. Herpesviruses in endodontic pathoses: association of Epstein-Barr virus with irreversible pulpitis and apical periodontitis. Journal of Endodontics. 2009; 35: 23–29.

[20] Slots J, Sabeti M, Simon JH. Herpesviruses in periapical pathosis: an etiopathogenic relationship? Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2003; 96: 327–331.

[21] Dai L, DeFee MR, Cao Y, Wen J, Wen X, Noverr MC, et al. Lipoteichoic acid (LTA) and lipopolysaccharides (LPS) from periodontal pathogenic bacteria facilitate oncogenic herpesvirus infection within primary oral cells. PLOS ONE. 2014; 9: e101326.

[22] Sabeti M, Valles Y, Nowzari H, Simon J, Kermani‐Arab V, Slots J. Cytomegalovirus and Epstein-Barr virus DNA transcription in endodontic symptomatic lesions. Oral Microbiology and Immunology. 2003; 18: 104–108.

[23] Bandara H, Samaranayake LP. Viral, bacterial, and fungal infections of the oral mucosa: types, incidence, predisposing factors, diagnostic algorithms, and management. Periodontology 2000. 2019; 80: 148–176.

[24] Jakovljevic A, Andric M, Knezevic A, Miletic M, Beljic-Ivanovic K, Milasin J, et al. Herpesviral infection in periapical periodontitis. Current Oral Health Reports. 2018; 5: 255–263.

[25] Piperi E, Papadopoulou E, Georgaki M, Dovrat S, Bar Illan M, Nikitakis NG, et al. Management of oral herpes simplex virus infections: the problem of resistance. A narrative review. Oral Diseases. 2024; 30: 877–894.

[26] Slots J, Rams TE. Herpesvirus-bacteria pathogenic interaction in juvenile (aggressive) periodontitis. A novel etiologic concept of the disease. Periodontology 2000. 2024; 94: 532–538.

[27] Hassan AO, Lip GYH, Bisson A, Herbert J, Bodin A, Fauchier L, et al. Acute dental periapical abscess and new-onset atrial fibrillation: a nationwide, population-based cohort study. Journal of Clinical Medicine. 2021; 10: 2927.

[28] Saleh W, Xue W, Katz J. Diabetes mellitus and periapical abscess: a cross-sectional study. Journal of Endodontics. 2020; 46: 1605–1609.