Many patients associate root canal treatment with pain. Unfortunately, local anaesthetic techniques such as infiltrations and inferior alveolar nerve blocks are not very effective as single injections for acute irreversible pulpitis. This review discusses strategies for more effective pain management for such situations. Pain control before, during and after treatment is essential for effective patient management. Adequate pain control during treatment also reduces post-operative pain. Effective pain management begins with a thorough understanding of the conditions being treated and an accurate diagnosis. In some cases, premedication with non-steroidal anti-inflammatory drugs can help reduce intra-operative pain. Pain management during treatment involves standard local anaesthetic solutions and injection techniques plus increased volumes and supplementary injections. Once anaesthesia is achieved, treatment can be commenced and the root canal system can be medicated to relieve pain. These should be followed by flexible post-operative pain management strategies for the individual patient and specific condition.