Dental Trephination for Endodontic Pain: Ancient Surgery, Modern Evidence
Thousands of years before anesthesia or antibiotics, people were cutting openings into human skulls. Archaeologists have found evidence of trepanning across several civilizations, including ancient Peru, where remodeled bone indicates that some patients survived for years. But surviving surgery does not prove that it cured the condition being treated. Dentistry has a similar history, complete with prehistoric drilled teeth, pioneering surgeons, and a procedure whose appeal has often exceeded the clinical evidence supporting it.
A 4,500-year-old Egyptian mandible with two openings beneath an infected molar was once celebrated as evidence of an ancient dentist draining an abscess. Roger Forshaw, writing in the British Dental Journal, explains that infection itself may have created those openings. More persuasive evidence of deliberate dental drilling comes from prehistoric teeth in Colorado and Arizona. In 2004, Arizona State University anthropologist Christy G. Turner II described a molar from a woman who lived in northern Arizona between approximately AD 1300 and 1600. An unusual opening near extensive decay and an adjacent abscess suggests an attempt to treat disease, although nobody knows whether it relieved her pain.
By 1728, Pierre Fauchard was describing the trepanning of diseased teeth in Le Chirurgien Dentiste. His technique involved entering the tooth rather than drilling through the jawbone. In 1845, Simon P. Hullihen described accessing a tooth through the gingiva, bone, and root. By 1886, W. A. Bronson advocated drilling through alveolar bone toward an infected apex to establish drainage, prompting objections that the canal might offer a less invasive route. That same year, G. V. Black wrote about amputating diseased root apices and individual roots to preserve functional teeth. Black’s root resections were distinct from drainage trephination, but all these clinicians were wrestling with the same question. How much surgery is justified to relieve pain and save a tooth?
The American Association of Endodontists still recognizes trephination in its terminology. Its 2020 Glossary of Endodontic Terms describes perforation of the alveolar cortical plate or apical foramen to release accumulated exudate, while earlier AAE clinical guides discuss selected drainage indications. That recognition should not be mistaken for a recommendation to perform the procedure routinely. A clinical definition establishes what a procedure means, not whether it improves patient outcomes.
Consider the patient who arrives with a necrotic mandibular molar, spontaneous pain, marked percussion tenderness, and a periapical radiolucency. The traditional theory holds that drilling through the buccal plate relieves trapped pressure. But pain can arise from inflammatory mediators and sensitized nerve endings even when there is no collection of pus to evacuate. A radiolucency does not prove an abscess is waiting behind the cortical plate. The distinction between symptomatic apical periodontitis and an infection requiring drainage determines whether another surgical opening has any reasonable purpose.
Three randomized trials tested the pain relief theory. In 1996, Heidi Moos, J. Douglas Bramwell, and James Roahen studied 17 symptomatic patients. The six receiving pulpectomy with trephination reported significantly more pain four hours afterward than those receiving pulpectomy alone. In 2000, Vicki Houck and colleagues randomized 50 patients with symptomatic necrotic teeth to trephination or a simulated procedure after endodontic treatment. They found no significant reduction in pain, swelling, percussion sensitivity, or analgesic consumption. A 2001 study by Nist, Reader, and Beck enrolled another 50 patients and likewise found no significant improvement in pain or swelling, although trephination patients used less acetaminophen with codeine. Across 117 patients, these small trials offer little support for adding cortical perforation routinely to emergency endodontic care.
There is a legitimate counterargument. In a 2003 Journal of Endodontics article, Brian Henry and John Fraser described direct surgical drainage of selected periapical infections when adequate drainage through the tooth or soft tissue could not be established. That is a different situation from drilling into bone near a painful tooth with no demonstrated collection. Their report was based on clinical experience rather than randomized comparative evidence, so its success claims remain uncertain. Nonetheless, negative trials of routine pain relief do not invalidate drainage of a genuine abscess.
In the operatory, treatment begins with an accurate pulpal and periapical diagnosis, evaluation of restorability, assessment of swelling and systemic symptoms, and a plan to eliminate the source. Root canal treatment or extraction addresses the diseased tooth. An accessible abscess may warrant incision and drainage, while unusual intraosseous infections may require specialist surgical judgment. Antibiotics do not substitute for local treatment and are not routinely appropriate for otherwise healthy patients with localized pulpal or periapical disease. If a patient asks why the dentist cannot simply drill through bone to release pressure, the answer is that pain does not establish something is there to drain, and controlled trials have not shown dependable added relief.
Meanwhile, trephine burs have found another role in modern endodontic surgery. Targeted endodontic microsurgery combines CBCT, digital planning, printed guides, and hollow burs to reach selected root apices for resection and root end treatment. A 2021 retrospective report of 24 treated teeth classified 20 as completely healed, two as improved, and two as failures. Those results are encouraging but cannot establish superiority over conventional microsurgery without a comparative trial. Guided root end surgery and trephination solely for pain relief are different procedures, even if both involve making an opening through bone. For a failing root canal, treatment planning must also account for periodontal support, remaining tooth structure, the definitive restoration, and the patient’s priorities.
The larger lesson reaches beyond endodontics. Historical longevity, professional recognition, and newer equipment can make a procedure sound more convincing than its outcomes warrant. Before adding surgery, dentists should ask what disease they are treating, what benefit the patient is likely to receive, and whether a less invasive approach can accomplish the same goal.
When does drilling another hole in bone truly help the patient?
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