Unpacking the evidence: a deeper look at foraminal enlargement and postoperative pain outcomes

Abstract

A Commentary on

Fatima S, Andrabi S M, Alam S et al.

Effect of foraminal enlargement on postoperative pain in primary endodontic treatment: a systematic review and meta-analysis. J Endod 2025; 51: 1536–1548.

Objective

The purpose of this systematic review and meta-analysis was to investigate how foraminal enlargement (FE) affects postoperative pain following primary endodontic treatment.

Data sources

A systematic literature search was conducted across four major databases— PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library—to identify randomized controlled trials evaluating the impact of foraminal enlargement (FE) versus non-foraminal enlargement (NFE) on postoperative pain.

Methods

The risk of bias in the included studies was evaluated using the Revised Cochrane Risk-of-Bias Tool for Randomized Trials. A meta-analysis was planned to quantitatively assess the impact of foraminal enlargement (FE) on pain during the first 7 days following treatment

Results

Eight randomized controlled trials (RCTs) involving a total of 802 participants met the inclusion criteria. The risk-of-bias assessment indicated that two studies were at high risk, four raised some concerns, and two were at low risk. Meta-analysis demonstrated that foraminal enlargement (FE) was associated with significantly greater postoperative pain compared to non-foraminal enlargement (NFE) at 12 h (SMD = 0.79, 95% CI [0.30, 1.28], p = 0.002; I² = 28%), 24 hours (SMD = 0.74, 95% CI [0.12, 1.36], p = 0.02; I² = 89%), and 48 h (SMD = 2.90, 95% CI [0.23, 5.57], p = 0.03; I² = 98%).

Conclusion

This meta-analysis indicates that postoperative pain is markedly elevated following foraminal enlargement (FE) compared to non-foraminal enlargement (NFE) during the initial 48-hour period, although such pain is generally mild to moderate and transient. Future investigations are warranted to delineate the impact of FE on essential clinical outcomes, including long-term success rates, and to determine whether its prospective advantages outweigh the attendant short-term increase in discomfort.