***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Effective management of  severe endodontic pain  is often a major problem . The analgesic effect of ketorolac tromethamine ( Toradol , 10 mg p.o . ) was compared with acetaminophen codeine ( 325 mg/15 mg p.o . ) in patients with severe pain due to acute apical periodontitis in a double-blind clinical study . A total of 66 patients presenting with severe pain ( defined as 7 cm and more using a visual analog scale ) were r and omly assigned to receive either ketorolac tromethamine or acetaminophen codeine ( 33 patients in each group ) , and recorded their pain score once every 10 min for 90 min after administration . Results indicate that patients in the ketorolac group had significantly less pain than those who received acetaminophen codeine ( p = 0.005 ) The purpose of this noninferiority trial was to compare postoperative pain relief after one-visit root canal therapy ( O RCT ) with a pulpotomy performed with a new endodontic calcium-enriched mixture cement ( PCEM ) in human permanent molars with irreversible pulpitis . A total of 407 selected patients were r and omly allocated into the O RCT group ( n = 202 ) or the PCEM group ( n = 205 ) . Numerical Rating Scale question naires were used to record pain intensity ( PI ) by the patients during the first 7 days after treatment . While there was no statistically significant difference in the mean PI at baseline between the two study groups ( P = 0.45 ) , changes in mean PI were significantly different between them ( P < 0.001 ) . In the O RCT group , pain relief was achieved after 36 h [ 95 % confidence interval ( CI ) , 27.00–45.00 ] , compared to 18 h in the PCEM group ( 95 % CI , 15.00–21.00 ) , a significant difference ( P < 0.01 ) . Comparison of the mean PI sum recorded over 7 days showed that patients in the O RCT group experienced significantly more pain than those in the PCEM group ( P < 0.001 ) ; a similar difference was observed for pain in response to percussion tests ( P < 0.001 ) . Treatment with PCEM thus had the better pain-reducing effects than O RCT in irreversible pulpitis cases Purpose The aim of this study was to compare the effect of white mineral trioxide aggregate ( MTA ) to that of formocresol ( FC ) as pulp dressing agents in pulpotomised primary molars . Methods In this clinical trial study , 60 lower second primary molars of 46 children were treated by a conventional pulpotomy technique . The teeth were r and omly assigned to the MTA ( experimental ) and FC ( control ) groups by r and om numbered table . Following removal of the coronal pulp and haemostasis , the pulp stumps were covered with an MTA paste in the experimental group . In the control group , FC was placed with a cotton pellet over the pulp stumps . The teeth of both groups were restored with stainless steel crowns . Children arrived for clinical and radiographic follow-up evaluation after 6 , 12 and 24 months . Results The treated teeth in FC group ( n = 18 ) were clinical ly and radiographically successful after 24 months . The radiographic follow-up evaluation revealed one failure ( furcation involvement ) in 18 molars treated with MTA after 24 months . The treated teeth in MTA group were clinical ly successful 24 months postoperatively . Pulp canal obliteration was observed in one of the teeth treated with MTA and four of the teeth treated with FC . Conclusion MTA could be used as a safe medicament for pulpotomy in cariously exposed primary molars and could be a substitute for FC Objectives Root canal therapy ( RCT ) and tooth extraction have been conventional treatment options for management of human mature teeth with irreversible pulpitis . Excellent short-term treatment outcomes of vital pulp therapy with calcium-enriched mixture cement ( VPT/CEM ) , as a new treatment option , on postoperative pain relief was demonstrated ; if intermediate- and long-term treatment outcomes of the new treatment are also non-inferior compared to RCT , then VPT/CEM may become a viable treatment option for management of mature teeth with irreversible pulpitis . Material s and methods In 23 healthcare centers , 407 9- to 65-year-old patients were r and omly allocated into two study arms including one-visit RCT ( reference treatment ; n = 202 ) and VPT/CEM ( alternative treatment ; n = 205 ) . Six- and twelve-month clinical and radiographic successes were assessed . Results Mean follow-up times at 6- and 12-month follow-ups were “ 6.70 ± 0.68 and 6.72 ± 0.71 months ” and “ 12.96 ± 0.67 and 12.90 ± 0.66 months ” in the available cases of RCT and VPT/CEM arms , respectively . Favorable clinical success rates in the two study arms did not show statistical difference ; however , the radiographic success rate in the VPT/CEM was significantly greater than RCT arm at the two follow-ups ( P < 0.001 ) . The patients ’ age had no effect on the treatment outcomes ( P = 0.231 ) . Conclusions Treatment outcomes of VPT/CEM may be superior to RCT in mature molars with irreversible pulpitis . The performance of bio material s such CEM cement may assist in the shift towards more biologic treatments . Clinical relevance VPT/CEM may be a realistic alternative treatment for human mature molar teeth with symptoms of irreversible pulpitis ; the use of VPT/CEM is highly beneficial for patients as well as general dentists OBJECTIVE To conduct a r and omized clinical trial to compare the post-operative pain experience as well as clinical and radiographic outcomes of pulpotomy in human permanent molars with irreversible pulpitis using calcium enriched mixture ( CEM ) cement or mineral trioxide aggregate ( MTA ) . MATERIAL S AND METHODS A total of 413 patients met the inclusion criteria and consented to participate . The patients were r and omly allocated into two study arms : MTA pulpotomy ( PMTA : n = 208 ) and CEM pulpotomy ( PCEM : n = 205 ) . Numerical rating scale question naires were utilized by the patients to record pain intensity ( PI ) over 7 days post-operatively . The patients were followed-up for 12 months to assess the clinical and radiographic outcomes of treatment . The data was analyzed using Chi-square , Cohen 's kappa and t-tests . RESULTS There was no significant difference in the mean PI recorded during the 7 post-operative days between the two study arms ( p = 0.221 ) . The clinical and radiographic success rates for PMTA at 12-month follow-up were 98 and 95 % , respectively ; and 97 and 92 % for PCEM , respectively . There was no significant differences in clinical ( p = 0.7 ) and radiographic ( p = 0.4 ) success rates between the two arms . CONCLUSIONS Excellent treatment outcomes occurred in molar teeth with irreversible pulpitis undergoing pulpotomy with MTA and CEM bio material Acute pain and swelling following endodontic treatment are a challenge for both the patient and the dentist . According to previous studies , the incidence of flare-ups increases after endodontic treatment of teeth with necrotic pulps . Calcium hydroxide is currently used as a multi- purpose drug in root canal therapy . The aim of this study was to evaluate the incidence and severity of flare-ups after treatment of pulpless teeth using calcium hydroxide as an intracanal dressing .  Sixty patients with single-root necrotic teeth participated in this study . These patients were r and omly divided into three groups of 20 . The patients were treated in Group A in a single-visit approach , in group B with a two-visit approach without any intracanal dressing and group C with a two-visit approach using calcium hydroxide as an intracanal dressing for one week . All of the patients were followed for 72 hours after each treatment session . The information about the incidence and severity of pain and swelling was recorded in tables , using a modified Visual Analogue Scale for pain severity measurement and a scale with four degrees for measuring the severity of swelling . The data were analyzed by chi-square test and GENMODE procedure INTRODUCTION Achieving pulp anesthesia with irreversible pulpitis is difficult . This study evaluated whether nonsteroidal anti-inflammatory drugs assist local anesthesia . METHODS In a r and omized double-blinded clinical trial , 150 patients ( 50 per group ) with irreversible pulpitis were given placebo , 600 mg ibuprofen , or 75 mg indomethacin 1 hour before local anesthesia . Each patient recorded their pain score on a visual analog scale before taking the medication , 15 minutes after anesthesia in response to a cold test , during access cavity preparation and during root canal instrumentation . No or mild pain at any stage was considered a success . Data were analyzed by the chi-square and analysis of variance tests . RESULTS Overall success rates for placebo , ibuprofen , and indomethacin were 32 % , 78 % , and 62 % , respectively ( p < 0.001 ) . Ibuprofen and indomethacin were significantly better than placebo ( p < 0.01 ) . There was no difference between ibuprofen and indomethacin ( p = 0.24 ) . CONCLUSIONS Premedication with ibuprofen and indomethacin significantly increased the success rates of inferior alveolar nerve block anesthesia for teeth with irreversible pulpitis AIM To compare the treatment outcomes of calcium-enriched mixture ( CEM ) cement and mineral trioxide aggregate ( MTA ) as pulp dressing bio material s in vital pulpotomy of carious primary molars . STUDY DESIGN split-mouth r and omised clinical trial . MATERIAL S AND METHODS Forty children aged 4 - 8 years with 2 carious teeth requiring pulpotomy were selected and r and omly assigned to MTA ( n = 40 ) or CEM ( n = 40 ) groups . After coronal pulp removal , the remaining radicular pulp was covered with an appropriate bio material ; the teeth were then permanently restored . Clinical /radiographic success/failures were blindly evaluated at 6- , 12- and 24-month follow-ups . STATISTICS the recorded data were analyzed with McNemar test and GEE . RESULTS A total of 36 , 33 and 35 patients were available for 6- , 12- and 24-month follow-ups , respectively . At the 12-month follow-up only one and three teeth in the CEM and MTA groups had pathologic external root resorption , respectively . The resorbed teeth were then missed due to extraction /exfoliation at the 24-month follow-up ; all other treated teeth were sign/symptom-free . Overall , clinical and radiographic outcomes in both MTA/CEM groups were comparable at the three follow-ups without significant differences . Time had no significant effect on the success . CONCLUSION MTA and CEM demonstrated favourable treatment outcomes for pulpotomy of carious primary molars ; CEM may be an effective pulp dressing bio material BACKGROUND Amitriptyline is one of the most common tricyclic antidepressants , which binds to pain sensory nerve fibers close to the sodium channel ; hence , it could interact to some degree with receptors of local anesthetics . This study was design ed to assess the additional analgesic effects of 2 % Amitriptyline local gel administration in irreversible pulpitis pain of the molars . MATERIAL S AND METHODS This study was a r and omized , double-blind clinical trial that was performed on 56 consented adult patients who did not receive enough analgesia after a lidocaine nerve block for their tooth pulpitis pain . Patients were treated with 0.2 ml of either 2 % amitriptyline or placebo , which was directly injected into their m and ibular molar pulp chamber after they had received two routine lidocaine injections . Patients were asked to score their pain as a mark on a 10-cm Visual Analogue Scale ( VAS ) at different timepoints : 0 ( just before gel administration ) , 1 , 3 , 5 , 7 , and 9 minutes after the treatments . RESULTS There was a 92.5 % decrease in VAS scores of patients 9 minutes after amitriptyline administration compared to Time 0 , while in the placebo group this difference was only 13.5 % . Further , in the amitriptyline group , the VAS score at all timepoints was statistically different from Time 0 ( P < 0.01 ) . The overall pain reduction and its trend was significantly higher in the amitriptyline group compared with the placebo group ( P < 0.001 ) . CONCLUSION Inter-pulp space administration of amitriptyline 2 % gel for completing analgesia in irreversible pulpitis pain could be effective and useful as a conjunctive therapy to injections of local anesthetics Previous papers in this series on evidence -based dentistry have discussed the first 2 steps in seeking answers to clinical problems formulating a clear question and strategically search ing for evidence . The next step , critical appraisal of the evidence , is made easier if one underst and s the basic concepts of clinical research design . The strongest design , especially for questions related to therapeutic or preventive interventions , is the r and omized , controlled trial . Questions relating to diagnosis , prognosis and causation are often studied with observational , rather than experimental , research design s. The strongest study design should be used whenever possible . Rules have been established to grade research evidence . This paper , the fourth in the series , 
    Output:
    
Vital pulp therapy was the most important topic amongst endodontic high level evidence articles