A Randomized Controlled Trial Evaluating Whether Pre-operative Trinase Reduces Post-operative Pain in Patients With Symptomatic Irreversible Pulpitis Compared to Placebo, Using VAS Scores and Analgesic Intake Over 48 Hours.

Symptomatic irreversible pulpitis is a common endodontic condition characterized by severe inflammatory dental pain. Although root canal treatment (RCT) is effective in removing the inflamed pulp tissue, many patients continue to experience pain during the first 24-48 hours after treatment. Post-operative endodontic pain affects patient comfort, satisfaction, and clinical workflow, making pain control an essential component of evidence-based endodontic care.

Traditional pharmacological methods for managing post-operative dental pain include nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. While these medications are effective, they are also associated with potential gastrointestinal and systemic adverse effects, especially when used repeatedly. As a result, there is growing interest in alternatives that can reduce inflammation and discomfort while minimizing systemic risks. Enzyme-based anti-inflammatory therapies, including combinations of trypsin, bromelain, and rutin, have been shown in medical and dental literature to provide meaningful reductions in pain, edema, and inflammation following surgical procedures. These proteolytic enzymes act by breaking down inflammatory mediators, reducing tissue permeability, and modulating cytokine responses. Trinase, a formulation containing trypsin, bromelain, and rutin, is widely used in postoperative care in other medical fields, yet its role in managing pain following endodontic procedures has not been adequately studied.

This randomized, double-blind, placebo-controlled clinical trial is designed to evaluate whether administering Trinase before root canal treatment can reduce the intensity of post-operative pain in patients diagnosed with symptomatic irreversible pulpitis. A total of 182 systemically healthy male patients, aged 18 to 50 years, will be recruited from the Endodontics Department at Fayoum University. The study population is limited to male participants to standardize biological pain variability and hormonal influences on pain perception. Eligible patients must present with restorable mandibular molar teeth and moderate to severe preoperative pain confirmed both clinically and radiographically.

Participants will be randomly assigned to one of two equal study arms. The Trinase group will receive a single oral Trinase tablet 30 minutes before treatment. The placebo group will receive a visually identical tablet administered under the same conditions. An assistant not involved in treatment will prepare and code all medication envelopes, ensuring allocation concealment. Both the operator and the participants will be blinded to group assignment.

All treatments will be performed in a single visit using standardized endodontic procedures. After local anesthesia, rubber-dam isolation, and access preparation, canal patency will be confirmed using stainless steel hand files. Working length will be determined electronically and confirmed radiographically. Mechanical instrumentation will be performed using Protaper Next rotary instruments according to manufacturer instructions. Irrigation will be performed using 2.5% sodium hypochlorite and EDTA gel lubricant. Upon completion of cleaning and shaping, canals will be dried, obturated using a modified single-cone technique with resin-based sealer, and restored temporarily with intermediate restorative material. All procedures are performed by a single experienced operator to eliminate inter-operator variability.

The primary outcome measure is postoperative pain intensity assessed using a 10-cm Visual Analogue Scale (VAS). Patients will record their pain levels at baseline and at 6, 12, 24, and 48 hours after treatment. Pain will be categorized using validated VAS cutoff values. The secondary outcome measure is the total number of analgesic tablets consumed within 48 hours following treatment. Participants will receive a standardized pain diary to document both pain levels and analgesic intake.

Statistical analysis will be conducted using non-parametric tests due to expected non-normal distribution of pain scores. Between-group differences will be analyzed using the Mann-Whitney test, and within-group comparisons across time points will be performed using the Friedman test followed by appropriate post-hoc analysis. The significance level will be set at p ≤ 0.05. Sample size was calculated using PS software to detect clinically relevant differences in postoperative pain with an anticipated dropout rate accounted for by enrolling 182 participants.

The study protocol has been reviewed and approved by the Fayoum University Supreme Committee for Scientific Research Ethics (FU-SCSRE). Written informed consent will be obtained from each participant. The study involves minimal risk, as Trinase is a commercially available medication with a well-established safety profile and the placebo carries no known risks. The duration of active participation for each subject is approximately 48 hours, corresponding to the postoperative observation period. No additional radiographs or invasive procedures beyond standard clinical care will be performed.

This study aims to determine whether Trinase can serve as a simple, safe, and effective adjunct to improve postoperative patient comfort following root canal therapy. The results may help clarify the role of enzyme-based anti-inflammatory medications in endodontic pain management and potentially reduce reliance on traditional analgesics with known adverse effects.

Inclusion criteria

• Systemically healthy male patients (ASA I or II)
• Aged 18 to 50 years
• Presenting with symptomatic irreversible pulpitis in a restorable mandibular molar
• Preoperative moderate to severe pain (VAS ≥45 mm)
• Normal periapical tissue (no radiolucency, pocket depth ≤5 mm, mobility ≤ Grade I)

Exclusion criteria

Medically compromised patients (ASA III or higher)

• History of allergy or intolerance to Trinase or any of its components (trypsin, bromelain, rutin)
• Vertical root fracture
• External or internal root resorption
• Periodontal pocket depth >5 mm
• Tooth mobility Grade II or III
• Presence of periapical lesion (radiolucency)
• Female patients (to standardize pain perception and hormonal factors)