Comparing Trypsin-Chymotrypsin and Naproxen Sodium for Post-Endodontic Treatment Pain: A Randomised Controlled Trial

By Hafsa Zaki, Shahbaz Ahmed Jat, Fazal-Ur-Rehman Qazi, Mahrukh Samee

Affiliations

1. Department of Operative Dentistry and Endodontics, Dr Ishrat-ul-Ibad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan

doi: 10.29271/jcpsp.2026.08.985

ABSTRACT
 Objective: To compare the efficacy and mean pain scores of trypsin-chymotrypsin and naproxen sodium for post-endodontic treatment pain.
Study Design: A randomised controlled trial.
Place and Duration of the Study: Department of Operative Dentistry and Endodontics, Dr Ishrat-ul-Ibad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan, from August 2024 to January 2025.
Methodology: A total of 100 patients were randomly allocated to receive oral formulations of the trypsin-chymotrypsin group (n = 50) or the naproxen sodium group (n = 50). The numeric rating scale (NRS) was utilised to assess pain score at 1, 6, 12, and 24-hour intervals. The Mann-Whitney U test was used for pre- and post-operative comparisons, and age and gender were stratified using the independent-sample t-test and chi-square test.
Results: There was no notable difference between the two groups in baseline characteristics or pre-operative pain (p >0.05). Pain scores were comparable at 1-hour intervals (p = 0.695); however, at 6 hours, the trypsin-chymotrypsin group showed a significant reduction in pain compared with the naproxen sodium group (p = 0.049). At 12- and 24-hour intervals, both groups showed zero pain scores (p = 0.999).
Conclusion: The efficacy of trypsin-chymotrypsin was comparable to that of naproxen sodium in reducing post-endodontic pain in teeth with symptomatic irreversible pulpitis.

Key Words: Postoperative pain, Non-steroidal anti-inflammatory agents, Trypsin-chymotrypsin, Root canal therapy, Pain, Numeric rating scale. 

INTRODUCTION

Pain—characterised as an adverse sensory and psycholo- gical reaction linked with injury to the tissues, whether real or anticipated—often leads patients to visit the dentist.¹ An estimate of 27% patients report a decrease in the quality of life associated with dental pain.² Root canal procedures, aimed at preventing or alleviating pain,³ can lead to post-endodontic dis- comfort and pain, especially in patients with acute irreversible pulpitis.^4,5 Post-endodontic pain affects 2.5–60% of patients.⁶ It is a major complication for both patients and dentists, contri-buting to increased dental anxiety and fear among patients and a subsequent reduction in dental attendance.⁷

Various factors contribute to this, including remnants of pulp tissue, inadequate irrigation, missed canals, working length errors, debris extrusion, obturation techniques,¹ and patient- specific factors such as age, gender, psychological aspects, and previous experiences.⁸ Managing postoperative pain in Endodontics is challenging, and despite numerous studies, there is no established, definitive analgesic and anti-inflam- matory protocol.⁴

Prostaglandins are crucial inflammatory mediators that aug- ment vascular permeability, recruit immune cells, cause fever, and heighten pain sensitivity. Inflammation from disease or endodontic treatment boosts prostaglandin levels, leading to increased  pain.⁹

NSAIDs block the cyclooxygenase enzyme, thereby reducing prostaglandin formation. While ibuprofen is considered safe, it may cause gastrointestinal toxicity. Other NSAIDs, such as diclofenac, naproxen, and etoricoxib, are also prescribed for pain, with naproxen offering a longer duration of analgesia and minimal cardiovascular side effects.^1,4 Despite the benefits, NSAIDs have limitations, leading to a search for alternatives with minimal side effects for enhanced patient comfort and safety.⁹

This led to the investigations of the effectiveness of proteolytic enzymes in the reduction of post-endodontic therapy pain.⁵

The trypsin-chymotrypsin complex, an oral proteolytic enzyme preparation, demonstrates anti-inflammatory, pain-alleviating, anti-oedematous, fibrinolytic, and antimicrobial effects, lead- ing to a quicker resolution of inflammation and superior pain alleviation compared with alternative proteolytic enzymes.⁵

Oral trypsin-chymotrypsin competes with plasmin for inhi-bitor binding, promoting fibrinolysis and tissue repair. These enzymes inhibit the release of pain-inducing amines, enh-ance antioxidant activity, and degrade large polypeptides, thereby helping to resolve oedema. Analgesic effects may result from anti-inflammatory actions and direct interaction with nociceptors, reducing pain mediators such as bradykinin.^5,10

Several studies have shown promising results using nap-roxen sodium as an effective modality for post-endodontic pain.^8,4 In contrast, other studies have reported trypsin- chymotrypsin to be an effective postoperative pain reduction modality after root canal treatment,⁵ maxillofacial trauma,¹¹ and impacted molar extractions.¹⁰ However, limited clinical evidence exists comparing the effectiveness of trypsin-chymotrypsin with commonly prescribed NSAIDs such as naproxen sodium for the alleviation of pain following endodontic therapy.

This study aimed to compare the efficacy of trypsin-chymo-trypsin and naproxen sodium for post-endodontic treatment pain in teeth with symptomatic irreversible pulpitis.

METHODOLOGY

It was a single-centre, randomised controlled trial, conduc-ted at the Department of Operative Dentistry and Endodon-tics, Dr Ishrat-ul-Ibad Khan Institute of Oral Health Sciences, Dow University of Health Sciences, Karachi, Pakistan, from August 2024 to January 2025, after getting approval from Institutional Review Board (Ref. No. IRB-3376/DUHS/Approval/ 2024/52; dated: 2 March 2024) and trial registration with the International trial registry ClinicalTrials.gov (Identifier: NCT 06562816). This trial was conducted in accordance with the CONSORT (Consolidated Standards of Reporting Trials) guidelines (Figure 1).

It included both male and female healthy patients, aged between 18 and 45 years, who were scheduled for root canal therapy for teeth in both maxillary and mandibular arches, diagnosed with symptomatic irreversible pulpitis. Patients requiring emergency endodontic treatment, those with any kind of periapical lesion around the affected tooth, those who had consumed analgesics within the previous 24 hours, those with any systemic, medical, or mental illness, and those with known allergies to the medicines used in this study were excluded.

Figure 1: Consolidated standards of reporting trials (CONSORT) flow chart.

After obtaining informed consent from the participants, they were randomly allocated to the trypsin-chymotrypsin group or the naproxen sodium group using an online randomisation tool (www.random.org). Allocation concealment was achieved by packing the medicines in securely sealed, opaque envelopes by an independent individual not associated with the study. Blinding was maintained for the researcher, participants, and outcome assessors.

The root canal procedure was initiated after the adminis-tration of local anaesthesia (2% lidocaine with 1:100,000 epinephrine). Access was obtained following the rubber dam application. Rotary files were employed for chemo-mecha-nical preparation, with generous irrigation with 5.25% sodium hypochlorite. The canals were obturated using single, pre-fitted gutta-percha cones. The teeth were restored with tem-porary restorations.

After the conclusion of the root canal therapy, patients were provided with sealed envelopes containing painkillers, depending on the group they were assigned to. They were asked to start taking medicines if they experienced any pain.

The first group (n = 50) received sealed envelopes containing an oral formulation of trypsin and chymotrypsin in a 6:1 ratio with an enzymatic activity of 100,000 A.U. per tablet (Chymoral Forte), to be taken three times daily, 30 minutes before meals for 24 hours. The second group (n = 50) was the active control group and received an oral formulation of naproxen sodium 550 mg (Tab. Synflex) to be taken twice a day, after meals for 24 hours.

Table I: The baseline characteristics of patients.

Variable		Groups		p-values
		Trypsin-chymotrypsin	Naproxen sodium
Age (years)	Mean ± SD	32.34 ± 7.17	31.36 ± 6.66	0.527
Gender	Male (n, %)	19 (38.0)	17 (34.0)	0.677
	Female (n, %)	31 (62.0)	33 (66.0)
The p-values were calculated by using an independent-sample t-test for age and a chi-square test for gender.

Table II: Comparison of NRS pain scores across groups and time points.

Time		Groups		p-values
		Trypsin-chymotrypsin	Naproxen sodium
Preoperative				0.832
1 hour	Median (Q1-Q3)	2 (0-3)	2 (0-4)	0.695
6 hours	Median (Q1-Q3)	0 (0)	0 (0)	0.049
12 hours	Median (Q1-Q3)	0 (0)	0 (0)	0.999
24 hours	Median (Q1-Q3)	0 (0)	0 (0)	0.999
A p-value was calculated by using the Mann-Whitney U test. A p-value of <0.05 was considered significant.

The Numeric Rating Scale (NRS-11), an eleven-point scale ranging from 0 (no pain) to 10 (the worst possible pain experienced by the patient), was utilised to assess postopera- tive pain following treatment of teeth with symptomatic irreversible pulpitis. Patients were asked to mark their pain intensity level at 1-, 6-, 12-, and 24-hour intervals. The questionnaires were collected at the next appointment, and the temporary restorations were replaced with permanent restorations.

Sample size was calculated using OpenEpi online software; pain at 24 hours was 0.8 ± 1.08 in the trypsin-chymotrypsin group⁴ and 0.94 ± 0.35 in the naproxen sodium group.¹² A sample size of 506 was achieved, providing 85% power at a significance level (α) of 0.05. Although the calculated sample size indicated a larger number, only 100 patients were included due to limited study duration, patient availability during data collection, and strict inclusion criteria. Considering feasibility within the study setting and the availability of eligible patients, a total of 100 patients were enrolled and equally divided into two groups of 50 patients each.

Data were analysed using SPSS version 26. Frequency and percentages were calculated for gender. The mean ± standard deviation was reported for age as it was normally distributed according to the Shapiro–Wilk test. The median with interquartile range (IQR) was reported for preoperative and postoperative pain scores (1, 6, 12, and 24 hours), as these variables were not normally distributed. An independent-samples t-test was used to compare age between groups, the Mann–Whitney U test was used to compare pain scores between groups at each time point, and Pearson’s chi-square test was used to assess the association between gender and groups. A p-value of ≤0.05 was considered statistically significant.

RESULTS

A total of 100 participants were included in the study and equally allocated to the trypsin-chymotrypsin group (n = 50) and the naproxen sodium group (n = 50). No participants were lost to follow-up. Baseline characteristics of the participants are presented in Table I. No statistically significant difference was observed between the groups in age or gender distribution (p >0.05).

Table II showed that the pre-operative pain scores were similar between the groups (p >0.05). At 1 hour, no statistically significant difference in pain scores was observed between the two groups (p = 0.695). However, at 6 hours, the trypsin-chymotrypsin group demonstrated a significantly lower pain score than the naproxen sodium group (p = 0.049). At 12 and 24 hours, pain scores decreased to zero in both groups, with no statistically significant difference obser-ved (p >0.05).

DISCUSSION

The current study found both of the drugs to be equally efficacious. Despite much research and advances, there is still no standard anti-inflammatory modality for pain reduction, especially for pain related to endodontic treatment.⁴

Post-endodontic treatment pain is the most common consequence after root canal treatment due to various causes such as residual pulpal remnants, improper irrigation, improper determination of working length, missed canals, wrong obturation technique, or extrusion of debris beyond the apex.¹ The literature showed that post-endodontic pain is higher in patients who undergo root canal treatment for vital teeth as compared to necrotic teeth.⁵

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) have been used mostly as a successful pain reduction modality for post-endodontic pain. A review conducted in Brazil in 2020 also found NSAIDs to be highly effective in alleviating pain after endodontic therapy.¹³ Among them, naproxen sodium has a long duration of action, reducing the cardiovascular side effects.¹⁴ Raoof et al. assessed the effectiveness of naproxen on postoperative pain after endodontic therapy in teeth with irreversible pulpitis and found it to be extremely effective in alleviating post-endodontic pain.⁸ This study had similar results to the study by Shami et al., who investigated the efficacy of naproxen sodium in reducing post-treatment endodontic pain in teeth with irreversible pulpitis.⁴ Islam et al. also assessed the efficacy of tramadol, ibuprofen, and naproxen sodium for pain after root canal preparation, and they found all three medicines to be equally effective in reducing pain.³ These results are consistent with the results of the present study, where naproxen sodium was found to be an excellent pain reduction modality for post-endodontic pain in teeth with symptomatic irreversible pulpitis; however, its chronic use led to some high renal and gastric side effects,¹⁵ which led to the need to find a better alternative.

Systemic enzyme therapy may be a preferable alternative to NSAIDs in certain clinical situations. Proteolytic enzymes, such as trypsin-chymotrypsin, have been widely reported in the literature as a modality for pain reduction.^5,10,16-18 The analgesic effect of trypsin-chymotrypsin may be attributed to its ability to modulate inflammatory nociceptive pathways involved in post-endodontic pain. Proteolytic enzymes reduce tissue oedema and inflammatory exudates, thereby decreasing interstitial pressure and mechanical stimulation of peripheral nociceptors. In addition, trypsin-chymotrypsin has been shown to reduce bradykinin-mediated nociceptor sensitisation, providing pain relief through resolution of inflammation rather than direct cyclooxygenase inhibition, unlike NSAIDs.^5,10

A randomised controlled trial conducted in 2021 compared trypsin-chymotrypsin with ibuprofen and a combination for post-endodontic pain reduction in teeth with symptomatic irreversible pulpitis for 72 hours and found the enzyme complex to be as effective as NSAIDs without the associated side effects.⁵ Apart from this, trypsin-chymotrypsin complex has been used as a successful pain reduction modality after impacted 3^rd molar surgeries, as investigated by Gandhewar et al.,¹⁶ Poddar et al.,¹⁰ and Menon et al.¹⁷ Trypsin-chymotrypsin has also improved the healing and pain perception in patients who underwent maxillofacial trauma.^11,18 The findings of these studies are in line with the results of the present study.

The NRS was utilised in the current study as a tool for measuring pain reduction because of its ease of use and reliability. It is one of the most frequently used assessment tools for evaluating complex post-endodontic pain and is easier to understand.¹⁹ Compared with other scales, the NRS demonstrates excellent reliability and sensitivity.²⁰

The current study has several notable strengths. First, the randomised controlled trial design ensured triple-blinding and reduced bias, thereby enhancing the reliability of the outcomes. Second, using naproxen sodium as an active control group enabled a more meaningful and effective comparison with a standard painkiller, increasing the clinical relevance. Third, assessing pain at intervals of 1, 6, 12, and 24 hours provided a detailed assessment of early post-operative pain, when pain is most intense, a period that has been overlooked in the literature. Fourth, conducting this trial in a hospital setting ensured consistent treatment protocols. Lastly, this study is the first to compare trypsin-chymo- trypsin with naproxen sodium for post-endodontic pain reduction in teeth with symptomatic irreversible pulpitis, adding novel insights to the literature.

The present study also has some limitations. It was a single- centre study, and the results may not be broadly generalisable to diverse settings and populations. A larger sample size would provide stronger evidence. An NRS was utilised to assess pain scores, which are highly subjective and can be influenced by patient perception. There was also a lack of calibration and inter-examiner reliability.

Future studies should explore a larger cohort of participants across multiple centres with a variety of endodontic conditions. In addition to patient-reported pain scores, objective measures such as medication consumption and inflammatory markers could strengthen the findings. Longer follow-up periods would also help determine whether trypsin- chymotrypsin provides sustained benefits compared with NSAIDs.
 

CONCLUSION

The current study found that the efficacy of trypsin-chymo- trypsin was comparable to that of naproxen sodium in redu-cing postendodontic pain in teeth with symptomatic irrever- sible pulpitis, with fewer side effects and greater patient comfort.

ETHICAL APPROVAL:
Ethical approval was obtained from the Institutional Review Board of Dow University of Health Sciences, Karachi, Pakistan (Ref. No. IRB-3376/DUHS/Approval/2024/52; dated: 2 March 2024).

PATIENTS’ CONSENT:
Written informed consent was obtained from all participants before enrolment in the study to publish the data concerning the study.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTIONS:
HZ: Design of the study, acquisition, analysis, and interpretation of the data.
SAJ: Review and final approval of the study to be published.
FURQ, MS: Drafting and revising it critically for important intellectual content.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Parmar S, Sreekumar D, Gupta A, Agrawal P, Kar SR, Priya A. Pain control in conservative dentistry and endodontics. J Pharm Negat Results 2022; 13.
2. Zanjir M, Sgro A, Lighvan NL, Yarascavitch C, Shah PS, da Costa BR, et al. Efficacy and safety of postoperative medications in reducing pain after nonsurgical endodontic treatment: A systematic review and network meta-analysis. J Endod 2020; 46(10):1387-402. doi: 10.1016/j.joen.2020. 06.011.
3. Islam S, Ali M, Shaikh A, Rashid S, Hosein T, Baloch J. Effects of three oral analgesics on postoperative pain following root canal preparation: A controlled clinical trial. Pak Armed Forces Med J 2021; 71(2):526-9. doi: 10.51253/pafmj. v71i2.3391.
4. Shami S, Subhan Z, Ahmed Rana MJ. Efficacy of naproxen in the management of postoperative endodontic pain in teeth with irreversible pulpitis. Pak Oral Dent J 2016; 36(3): 509-12. Available from: httpss://podj.com.pk/archive/Sep_2016/PODJ- 30.pdf.
5. Hashem AA, Abd El Sattar AA, Rahman TY. The effect of trypsin-chymotrypsin on postoperative pain after single-visit endodontic treatment: A randomised controlled trial. J Endod 2023; 49(3):240-7. doi: 10.1016/j.joen.2022.12.010.
6. Di Spirito F, Scelza G, Fornara R, Giordano F, Rosa D, Amato A. Post-operative endodontic pain management: An overview of systematic reviews on post-operatively administered oral medications and integrated evidence-based clinical recommendations. Healthcare (Basel) 2022; 10(5):760. doi: 10.3390/healthcare10050760.
7. Almuthhin M, Afify M, Alshammari Y, Alkatheeri N, Altuwaijri SM, Alhussain B, et al. The safety and efficacy of pre- and post-medication for postoperative endodontic pain: A systematic review and network meta-analysis. Open Dent J 2020; 14:563-99. doi: 10.2174/1874210602014010563.
8. Raoof M, Sadr A, Nazari F, Amanpour S, Nazeri M, Sadr S, et al. Effect of naproxen on postoperative pain in teeth with irreversible pulpitis. J Basic Res Med Sci 2015; 2(2):37-43. Available from: httpss://jbrms.medilam.ac.ir/browse.php?a_code= A-10-154-1&slc_lang=en&sid=1.
9. Abbas B, Abbas S, Sattar M, Rahim S, Amir S. Comparison of efficacy of celecoxib versus naproxen for post-endodontihc pain. Pak Armed Forces Med J 2020; 70(4):1133-7. Available from:httpss://psa.pastic.gov.pk/SearchArticleView.aspx?articledetailId=129431&S_id=13084.
10. Poddar VK, Kapoor S, Arora SS, Kumari K, Kour T, Kour R. Trypsin-chymotrypsin as an adjuvant to diclofenac potassium on postoperative sequelae following mandibular third molar impaction: A comparative study. Oral Surg 2022; 15(4): 523-30. doi: 10.1111/ors.12742.
11. Menon VD, Muthusekhar MR. Effectiveness of trypsin-chymotrypsin as an anti-inflammatory in maxillofacial trauma: A double-blinded randomised clinical trial. Int J Dent Oral Sci 2021; 8(7):3196-200. doi: 10.19070/2377-8075-21000651.
12. Khahro MM, Tareen T, Soomra AB, Baloch F, Alarifi A, Maqbool A. Comparison of naproxen and combination therapy (naproxen and gabapentin) in post-extraction pain relief. Prof Med J 2022; 29(11):1714-20. doi: 10.29309/TPMJ/2022.29.11.6965.
13. Santini M, Da Rosa RA, Ferreira MB, Barletta F, Do Nascimento AL, Weissheimer T, et al. Medications used for prevention and treatment of postoperative endodontic pain: A systematic review. Eur Endod J 2021; 6(1):15-24. doi: 10. 14744/eej.2020.85856.
14. Akpinar KE, Kaya F. Effect of different clinical practices on postoperative pain in permanent mandibular molar teeth with symptomatic apical periodontitis: A randomised controlled clinical trial. Niger J Clin Pract 2021; 24(1):8-16. doi: 10.4103/njcp.njcp_16_20.
15. Domper Arnal MJ, Hijos-Mallada G, Lanas A. Gastrointestinal and cardiovascular adverse events associated with NSAIDs. Expert Opin Drug Saf 2022; 21(3):373-84. doi: 10.1080/ 14740338.2021.1965988.
16. Gandhewar T, Andrade NN, Aggarwal N, Choradia S, Mathai PC, Nerurkar S. The effects of systemic proteolytic enzyme therapy on pain and swelling in third molar surgery equal to diclofenac therapy: A prospective randomised double-blinded clinical trial. Oral Maxillofac Surg 2020; 24(4):461-8. doi: 10.1007/s10006-020-00854-7.
17. Menon VD, Muthusekhar MR. Effectiveness of anti-inflammatory properties of bromelain, trypsin and rutoside compared with diclofenac and serratiopeptidase following surgical removal of impacted mandibular third molars: A randomised double-blinded clinical trial. Int J Dent Oral Sci 2021; 8(9):4217-21. doi: 10.19070/2377-8075-21000859.
18. Kondreddy S, Palli S. Proteases and tissue repair: Perioperative role of trypsin-chymotrypsin in surgical patients. Int Surg J 2019; 6(1):283-6. doi: 10.18203/2349-2902.isj20 185488.
19. Hatipoglu FP. Assessment of pain scales used in endodontic postoperative pain evaluation: Frequency, advantages, and limitations. J Endod Restor Dent 2024; 3(1):2-5. doi: 10. 5281/zenodo.14510700.
20. Spohr AR, Xavier SR, Malta CP, Pereira-Cenci T, Pappen FG, Morgental RD. Postoperative pain after endodontic reintervention: A randomised clinical trial. Braz Dent J 2022; 33(1):18-27. doi: 10.1590/0103-6440202204785.