Abst ract
Submitted: April 4, 2016 0RGL¿FDWLRQ$XJXVW Accepted: August 30, 2016
Post operat ive pain int ensit y aft er
using different inst rum ent at ion
t echniques: a random ized clinical
st udy
Post operat ive pain is a frequent com plicat ion associat ed wit h root canal t reat m ent , especially during apical inst rum ent at ion of t oot h wit h preexist ing
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int ensit y of post operat ive pain in single-visit root canal t reat m ent . Mat erial and Met hods: Ninet y pat ient s wit h single root / canal and non-vit al pulps were included. The pat ient s were assigned int o 3 groups according t o root canal
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t echniques. Root canal t reat m ent was carried out in a single visit and t he severit y of post operat ive pain was assessed via 4- point pain int ensit y scale. All t he part icipant s were called t hrough t he phone at 12, 24 and 48 h t o obt ain
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rot at ional ( p= 0.018) and reciprocal ( p= 0.020) t echniques. No difference was found between the reciprocal and rotational techniques ( p= 0.868) . Postoperative
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h period was st at ist ically different bet ween t he groups ( p= 0.040) . Conclusion:
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t echniques.
Ke yw or ds: Endodont ics. I nst rum ent at ion. Post operat ive pain.
Ersan ÇIÇEK1
Mustafa Murat KOÇAK1
Sibel KOÇAK1 %DUDQ&DQ6$ö/$01
Sevinç Aktemur TÜRKER1
http://dx.doi.org/10.1590/1678-77572016-0138
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I nt roduct ion
Post operat iv e pain is a fr equent com plicat ion associat ed wit h root canal t reat m ent , and can be influenced by insufficient r oot canal pr eparat ion, e x t r u s i o n o f i r r i g a n t , d e b r i s o r i n t r a c a n a l i n t e r a p p o i n t m e n t m e d i c a m e n t , p r e s e n c e o f preoperative pain, presence of periapical pathosis, and apical pat ency during root canal inst rum ent at ion1,22. The apical ext rusion of irrigant and debris, including bacteria and necrotic tissue, m ay lead to postoperative
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ups23. Even though all instrum entation techniques and
inst rum ent s are associat ed wit h debris ext rusion, t he
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m ay affect t he am ount of debris ext rusion6.
Recent studies have dem onstrated that reciprocating syst em s can produce ext rusion of debris in t he apical region, which could be relat ed wit h post operat ive pain when com pared with other traditional instrum entation
t echniques8,15. Reciprocat ing m ot ion m ay increase
t he am ount of debr is ex t r uded beyond t he apex
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com pared t o rot ary inst rum ent at ion5,6. I n a recent
UDQGRPL]HGGRXEOHEOLQGVWXG\6KRNUDQHKHWDO24 ( 2016) dem onst rat ed t hat post operat ive pain was
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Pr oTaper Nex t ( Dent sply Maillefer, Ballaigues,
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fat igue r esist ance. This sy st em is designed w it h progressive and regressive percent age t apers, and an off- cent ered rect angular cross sect ion for superior
VWUHQJWKWRLPSURYHFDQDOVKDSLQJHI¿FLHQF\4,12. The recent ly int roduced inst rum ent at ion syst em WaveOne ( Dentsply Maillefer, Ballaigues, Switzerland) is claim ed to be able to com pletely prepare root canals wit h a single inst rum ent . The WaveOne inst rum ent s
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from M- wire Ni-Ti alloy. This syst em has pot ent ial advant ages such as reduced num ber of inst rum ent s and t he elim inat ion of cross- cont am inat ion depending on t he single use of t hese inst rum ent s15,26.
I n general, post operat ive pain begins w it hin a few hours aft er root canal procedures and frequent ly
requires unscheduled visit s22. Alt hough t he reasons
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in periapical pressure, in t he num ber or virulence of endodont ic m icrobiot a, or in environm ent al condit ions m ay be possible reasons25.
The root canal t reat m ent of t oot h wit h necrot ic pulp and apical periodont it is can be com plet ed in single or m ult iple visit s. Clinical st udies dem onst rat ed t hat pat ient s generally t olerat e and prefer single-visit root canal t reat m ent21 because of several advant ages, such as reduct ion of operat ive procedures17, no int
er-DSSRLQWPHQWOHDNDJH3, being less t im e consum ing and m ore econom ical28.
The aim of t he present st udy was t o com pare t he incidence and intensity of postoperative pain related to different root canal instrum entation techniques during single visit root canal t reat m ent . The null hypot hesis of t his st udy was t hat t he inst rum ent at ion t echnique does not affect t he int ensit y of post operat ive pain.
Mat erial and m et hods
Th is clin ical st u d y w as p er f or m ed u n d er t h e regulations of the ethics com m ittee ( protocol num ber: 2013- 116- 01/ 10) . The pr oj ect w as r egist er ed at
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NCT02566486) . Asym pt om at ic necrot ic m axillary and m andibular t eet h which had single st raight root canal wit h apical radiolucency and periodont al probing of at m ost 3 m m dept h were included in t he st udy. On t he ot her hand, pat ient s wit h sinus t ract , periapical
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any m edicat ion, and who had t oot h wit h any type of previous root canal t reat m ent were excluded.
The pat ient s had no sym pt om s before t reat m ent and were in good health, as determ ined from a written healt h hist ory and oral int erview. Age, gender, t oot h locat ion, pulp sensibilit y, and radiographically visible lesions ( t eet h wit h loss of lam ina dura and apically periodont al ligam ent enlargem ent of > 2 m m were
FODVVL¿HGDVKDYLQJOHVLRQVRIHQGRGRQWLFRULJLQ19) were recorded. Therm al t est and an elect ric pulp- t est ing device ( Elem ent s pulp vit alit y t est er, SybronEndo, Orange, CA, USA) were used t o assess t he sensibilit y of t he pulp.
Overall, 90 pat ient s who had asym pt om at ic, non-vit al t eet h associat ed wit h periapical lesions were included.None of t he t eet hwere t ender t o percussion
and palpat ion. The ages of pat ient s ranged bet ween
from each pat ient before root canal t reat m ent was init iat ed. All diagnoses and t reat m ent procedures were perform ed by a single operat or t o elim inat e or m inim ize individual variabilit y in t he t reat m ent bet w een clin ician s. Th e pat ien t s w er e r an dom ly allocated to 3 groups of 30through coin toss. Allocation was perform ed by a second operat or blinded t o t he t reat m ent procedure. The groups were as follows;
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Ballaigu es, Sw it zer lan d) . A m in im al pr elim in ar y inst rum ent at ion was perform ed using a 15/ .02 hand
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2 and 3 gat es- glidden burs aft er m inim al prelim inary inst rum ent at ion. The root canals were prepared t o a
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of t he apical port ion.
Reciprocal t echnique ( n= 30) : The canals w ere inst r um ent ed w it h an engine dr iven r ecipr ocat ion
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am plit ude lim it com bined wit h a brushing m ot ion. The
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Rot at ional t echnique ( n= 30) : The canals w er e
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sequence X1, X2, X3, and X4 at a rot at ional speed of 300 rpm and 200 g/ cm t orque according t o t he m anufact urer ’s inst ruct ions. The inst rum ent s were
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Aft er isolat ion and access cavit y preparat ion, in all
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wit h a size 10 K- File 0.5 m m beyond t he apex. The
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elect r onic r oot canal m easur em ent dev ice ( Root
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m easurem ent device, was advanced apically int o t he canal unt il t he screen showed zero. The lengt h of t he
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periapical radiographs. During instrum entation, a total of 10 m l of 5.25% NaOCl were used for irrigat ion. The irrigat ion needle ( NaviTip 31 gauge needle; Ult radent ,
South Jordan, UT, USA) was placed as deep as possible int o t he canal wit hout resist ance unt il it was 1 m m
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5 m l 17% EDTA, and 5 m l 2% chlorhexidine. To prevent any react ion bet ween NaOCl, EDTA and chlorhexidine, 5 m l dist illed wat er was used following each irrigat ion solut ion.
The root canals were obt urat ed wit h gut t a- percha and an epox y- r esin based sealer ( AH26, De Tr ey Dent sply, Konst anz, Ger m any ) using cold lat eral com pact ion t echnique. A st andardized gut t a- percha
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lengt h. The gut t a- percha cone was light ly coat ed wit h t he sealer and slowly insert ed int o t he canal. Then,
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w it hdraw n; a size 15/ .02 gut t a- per cha accessor y cone, coated with a thin layer of the sealer, was placed int o t he space creat ed by t he spreader. Cold lat eral com pact ion wit h accessory gut t a- percha cones was perform ed unt il t he cones could not be insert ed m ore t han 5 m m int o t he root canal. Aft er radiographic confir m at ion of t he obt urat ion, cor onal seal w as provided wit h a dent al adhesive and com posit e resin,
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was perform ed. All canals were shaped, cleaned, and obt urat ed in a single visit . No syst em ic m edicat ion for post operat ive pain was prescribed.
The assessm ent of post operat ive pain was carried out at 12, 24, and 48 hours aft er t reat m ent by one in depen den t clin ician blin ded t o t h e gr ou ps. All part icipant s were called t hrough t he phone at 12, 24 and 48 h t o obt ain t he pain scores using a 4- point pain
int ensit y scale7. The presence, absence, and degree
of pain were recorded. The pain cat egories were as follows:
1- no pain;
2 - slig h t p ain ( m ild d iscom f or t , n o n eed f or t reat m ent ) ;
3- m oderat e pain ( pain relieved by analgesics) ; 4- severe pain ( pain and/ or swelling not relieved by sim ple analgesics and unscheduled visit required) .
Out com e m easures
or any com plicat ions such as post operat ive swelling or parest hesia.
All t hese m easures were recorded in t he pat ient ’s chart .
St at ist ical analysis
St at ist ical an aly sis w as p er f or m ed w it h t h e SPSS 19.0 soft ware ( SPSS I nc., Chicago, I L, USA) . Descr ip t iv e st at ist ics w er e ex p r essed as m ean and st andard deviat ion. The norm alit y of t he dat a was analy zed w it h t he Kolm ogor ov- Sm ir nov t est . Differences am ong t he groups were analyzed t hrough
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evaluat ed wit h t he Friedm an t est . P value of less WKDQZDVFRQVLGHUHGVWDWLVWLFDOO\VLJQL¿FDQWIRU
all t est s.
Result s
Th e pat ien t s en r olled in t h e clin ical t r ial ar e
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dat a are shown in Table 1. All t reat ed t eet h were
asym pt om at ic and associat ed wit h periapical lesion. Non e of t h e p at ien t s r eq u ir ed an u n sch ed u led appoint m ent for em ergency t reat m ent . No pat ient report ed any ot her sym pt om s or com plicat ions such as postoperative swelling or paresthesia. The intensity of post operat ive pain is shown in Table 2. The pain cat egories ranged bet ween 1 ( no pain) and 4 ( severe
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hours. The incidence and int ensit y of post operat ive pain in all groups gradually reduced over t he st udy period. The percent ages found in each score assigned t o each group are shown in Table 3.
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sig n if ican t ly low er p ost op er at iv e p ain t h an t h e r ot at ion al ( p = 0 . 0 1 8 ) an d r ecip r ocal t ech n iq u es (p= 0.020). However, no difference was found between t he rot at ional and reciprocal t echniques ( p= 0.868) .
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in t he 12 h ( p= 0.763) and 24 h periods ( p= 0.147) bet ween t he inst rum ent at ion t echniques. However, post operat ive pain in t he 48 h period was st at ist ically different bet ween all groups ( p= 0.04) .
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How ev er, n o d if f er en ce w as f ou n d b et w een t h e r ot at ion al ( p = 0 . 1 2 0 ) an d r ecip r ocal t ech n iq u es ( p= 0.191) in t erm s of t im e periods.
Discussion
Several fact or s including age, sex , pulpal and periradicular st at us, t ype of t oot h, preoperat ive pain, and t echnical aspect s m ay affect t he occur r ence
of post operat ive pain29. Am ong t hese fact ors only
technical aspects including instrum entation, irrigation, and obt urat ion prot ocols are under t he operat or ’s cont r ol. Ther efor e, sever e post operat ive pain can be avoided by providing a well- cleaned and shaped can al an d by m in im izin g t h e ex t r u sion of can al contents during the process11. Several factors, such as preoperat ive diagnosis, t he abilit y t o obt ain infect ion control, root canal anatom y, procedural com plications,
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m ult iple-visit endodont ics. However, bot h t reat m ent m odalit ies dem onst rat ed sim ilar success rat es for t he treatm ent of teeth with apical periodontitis18. Generally, t he pat ient s bet t er t olerat e and prefer single-visit root canal t reat m ent12. Addit ionally, single-visit root canal t reat m ent has becom e a com m on pract ice in non-vit al cases and offers several advant ages, including
a decreased num ber of operat ive procedures13 and
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t em por ar y r est or at ion s2 2. Th er ef or e, con sider in g t he pr ev iously m ent ioned advant ages, r oot canal t reat m ent procedures w ere com plet ed in a single appoint m ent in t he present st udy.
Various scales and m et hods have been used t o evaluat e t he severit y of post operat ive pain aft er root canal t reat m ent including t he 5- Level Pain Scale19, pain intensity in both num eric and verbal scores (using VAS)20, and t he 4- point pain int ensit y scale9. I n t he
Baseline demographic characteristic
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technique (n=30)
Reciprocal technique (n=30)
Rotational technique (n=30)
P-value
Gender Male (%) 16 (53.33) 15 (50) 16 (53.33)
Female (%) 14 (46.67) 15 (50) 14 (46.67)
Age Mean 35.6 39.6 36
Range 21-56 22-63 21-65
Location Maxillary 9 (30) 13 (43.33) 12 (40)
Mandibular 21 (70) 17 (56.66) 18 (60)
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Table 1- Baseline demographic characteristic of patients in each group
Group 12 h 24 h 48 h
Mean ± SD Mean ± SD Mean ± SD
0RGL¿HGVWHSEDFNWHFKQLTXH 1.4 ± 0.563aA 1.2 ± 0.407bB 1.07 ± 0.254cC
Reciprocal technique 1.67 ± 0.959dA 1.53 ± 0.730dB 1.40 ± 0.675dD
Rotational technique 1.57 ± 0.858eA 1.43 ± 0.626eB 1.33 ± 0.547eD
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Group 12 h 24 h 48 h
1 2 3 4 1 2 3 4 1 2 3 4
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technique 63.3 33.3 3.34 0 80 20 0 0 93.3 6.67 0 0
Reciprocal technique 60 20 13.3 6.67 60 26.6 13.3 0 70 20 10 0
Rotational technique 60 30 3.33 6.67 63.3 30 6.67 0 70 26.6 3.33 0
present st udy, a 4- point pain int ensit y scale was used
which is considered adequat ely valid and reliable9. A
m axim um 48 h t im e period was select ed t o evaluat e post operat ive pain, since t he prevalence and severit y
RISDLQVXEVWDQWLDOO\GHFUHDVHZLWKLQWKH¿UVWGD\V23. I n t he present st udy, t he effect of t hree different inst r um ent at ion t echniques on post operat ive pain was evaluat ed in t hree different t im e periods. Fact ors
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including apical foram en diam et er, t he t y pe and quant it y of irrigant solut ion were st andardized in all groups.
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introduced ProTaper Next instrum ents on postoperative pain. According t o t he result s of t he present st udy,
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post operat ive pain t han t he ot her t echniques. Thus, the null hypothesis was rejected. This result contrasted with previous studies2,10,19. Arias, et al.2 (2015) reported higher post operat ive pain for m anual inst rum ent at ion com pared t o rot ary inst rum ent at ion. Sim ilarly, Wei, et al.30 ( 2003) report ed less post operat ive pain wit h
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Pasqualini, et al.19 ( 2012)report ed less post operat ive
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com pared t o m echanical preparat ion wit h Pat hFiles. These conflict ing r esult s could be r elat ed t o t he discr epancies of inst r um ent at ion t echniques and syst em s used for inst rum ent at ion of root canals.
The r ecipr ocal and r ot at ional inst r um ent at ion t echniques caused sim ilar incidence and int ensit y of post-operative pain. However, the reciprocal technique dem onst rat ed slight ly higher pain scores t han t he
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post operat ive pain when shaping wit h WaveOne or ProTaper Next6,11,15.
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post operat ive pain bet ween t he t hree groups m ight be at t ribut ed t o t he ext rusion of debris8, which is
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Apical debris extrusion can cause periodontal ligam ent
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and consequently peripheral sensitization characterized as hyperalgesia, allodynia, and spont aneous pain
FDQ WDNH SODFH14. I n addit ion, a recent syst em at ic review and m et a-analysis st udy dem onst rat ed t hat
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design6.
A large num ber of studies have dealt with the effect of various root canal inst rum ent at ion t echniques on t he am ount of t he apically ext ruded dent inal debris and irrigant . The apical ext rusion of debris following t he reciprocal ( WaveOne) and rot at ional ( ProTaper Next ) t echniques was previously evaluat ed and was found t o be sim ilar for bot h t echniques16,26. I n cont rast t o t hese result s, som e previous st udies report ed t hat rotational instrum ents showed higher debris extrusion t han reciprocal inst rum ent s8,27. On t he ot her hand,
%UNOHLQ 6FKlIHU5 ( 2012) concluded t hat t he full sequence rotary instrum entation was related with less debris ext rusion t han t he reciprocal inst rum ent at ion
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discrepancies in t he experim ent al set up, design, and type of t eet h used.
The result s of t he present st udy dem onst rat ed t hat t he m ean scores of post operat ive pain gradually decreased t hroughout t he 12 h- 48 h periods. None of the patients reported an increase in pain intensity from 12 h t o 48 h which is in accordance wit h a previous
¿QGLQJ20.
I n con clu sion , all in st r u m en t at ion t ech n iqu es caused post operat ive pain. The m ean pain scores dem onst rat ed t hat all t echniques produced slight pain that caused m ild discom fort and no need for additional
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rot at ional and reciprocal t echniques especially in t he 48 h period. The effect of inst rum ent at ion t echniques on t he incidence and int ensit y of post operat ive pain should be well- evaluat ed.
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Ecevit University (grant num ber: 2013-27194235-03).
References
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