ABSTRACT
http://dx.doi.org/10.1590/1678-775720160136
The effect of various kinem at ics on post operat ive
p a i n a f t e r i n st r u m e n t a t i o n : a p r o sp e ct i v e ,
random ized clinical st udy
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Ataturk University, Faculty of Dentistry, Department of Endodontics, Erzurum, Turkey.
Corresponding address: Hakan Arslan - Department of Endodontics, Faculty of Dentistry, Ataturk University
Erzurum, 35620 - Turkey - Phone: +90.442.325 4040- 2352 - Fax: +90.442.325 2535 - e-mail: [email protected]
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bj ect ive: To evaluat e var ious kinem at ic m ovem ent s on post operat ive pain using a Recipr oc syst em . Mat er ial and Met hods: Fift y- six m olar t eet h w er e divided int o four gr oups accor ding t o kinem at ics as follow s: cont inuous r ot at ion, 360° CCW – 30° CW, 270° CCW – 30° CW, and 150° CCW – 30° CW. Pr eoperat ive a nd post operat ive pain levels using visual analogue scale ( VAS) , per cussion pain, and analgesic int ake w er e r ecor ded for each subj ect . Post operat ive pain levels at 1, 3, 5, and 7 d w er e evaluat ed. Dat a w er e analyzed st at ist ically using t he Kr uskal- Walis, Mann- Whit ney- U, one- way analysis of var iance, and chi- squar e t est s ( p= 0.05) . Result s: Cont inuous r ot at ion r esult ed in m or e pain at Day 1 w hen com par ed w it h t he r ecipr ocat ing gr oups ( 360° C CW – 30° CW and 270° CCW – 30° C) ( p< 0.05) . Conclusions: Cont inuous r ot at ion r esult ed in m or e post operat ive pain at DayWKDQLQUHFLSURFDWLQJJURXSVDQGWKHUHDIWHUQRVLJQL¿FDQWSDLQZDVIRXQGDPRQJWKH
gr oups.
Ke yw or ds: Apically ext ruded debris. Reciproc. Mot ion. Endodont ic t reat m ent . Post operat ive
pain.
I N TROD UCTI ON
One of t he m ost im port ant m at t ers in endodont ic t r eat m ent is t he pr event ion of pain. Post operat ive p ain af t er en d od on t ic t r eat m en t is a f r eq u en t com plicat ion. Accor ding t o a sy st em at ic r ev iew, t he fr equency of endodont ic post operat ive pain in pat ient s is bet w een 3% and 58%11. Post operat ive pain can be affect ed by alm ost all of t he procedures in r oot can al t r eat m en t , in clu d in g an aest h esia adm inist rat ion6, int r oduct ion of glide pat h8, use of inst r um ent at ion syst em s4,5, and r et r eat m ent13.
Recipr oc syst em ( VDW, Munich, Ger m any) is charact er ized by an S- shaped cr oss sect ion. I t has sharp cut t ing edges and a non- cut t ing t ip. I t shapes t h e can als w it h a r ecip r ocal b ack- an d - f or w ar d m ot ion ( 150 degrees count erclockw ise and t hen 30
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R50 ( 50/ 0.05)2. These inst r um ent s ar e pr oduced w it h a special NiTi alloy ( M w ir e) subj ect ed t o a
special t her m al t r eat m ent pr ocess, per for m ed t o
SURYLGHKLJKHUÀH[LELOLW\WRWKHLQVWUXPHQW9. Pr ev i o u s st u d i es h av e r ep o r t ed co n f l i ct i n g r e su l t s o n p o st o p e r a t i v e p a i n r e g a r d i n g t h e effect of inst r um ent at ion using r ecipr ocat ing and r o t a t i o n4 , 5. Neel a k a n t a n a n d Sh a r m a4 ( 2 0 1 5 ) evaluat ed post operat ive pain aft er inst r um ent at ion of r oot can als w it h a sin g le- f ile r ecip r ocat in g ( Recipr oc) an d r ot ar y ( On e Sh ape, Micr oMega,
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of post operat ive pain t han One Shape. How ever, Nekoofar, et al.5 ( 2015) com par ed t he int ensit y and durat ion of post operat ive pain using WaveOne and Pr oTaper Univ er sal, sy st em s for r oot canal inst rum ent at ion, and found t hat post operat ive pain
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in st r u m en t at ion w it h Pr oTaper Un iv er sal r ot ar y inst r um ent s t han w it h t he WaveOne r ecipr ocat ing
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designs and/ or t he num ber of inst r um ent s used. We believe t hat t her e is not hing about t he effect of differ ent kinem at ics using t he sam e inst r um ent s on post operat ive pain in t he lit erat ur e. Ther efor e, t he pur pose of t his st udy w as t o evaluat e four ( com binat ions of ) kinem at ic m ovem ent s [ count er clockw ise ( CCW) cont inuous r ot at ion, 360° CCW – 30° clockwise ( CW) , 270° CCW – 30° CW, and 150° CCW – 30° CW] regarding post operat ive pain using j ust one t ype of inst r um ent , a Recipr oc syst em . The null hypot hesis was t hat t her e is no differ ence am ong t he gr oups in post operat ive pain.
M ATERI AL AN D M ETH OD S
The pr ot ocol w as appr ov ed by t he Resear ch Et hics Com m it t ee. Sam ple size was calculat ed as 56 wit h a power of 0.80 ( effect size= 0.46) . A t ot al of 56 pat ient s w er e select ed for t his in vivo st udy. St udy subj ect s w er e r ecr uit ed fr om t he pool of pat ient s r efer r ed t o t he Depar t m ent of Endodont ics for r oot canal t r eat m ent fr om May 2015 t o Oct ober 2015 ( 6
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I n clu sion cr it e r ia
1 - Healt h y p at ien t s w it h ou t an y sy st em at ic diseases or aller gic r eact ions;
2- Toot h r esponsive t o cold t est ;
3 - Pat i en t s w i t h m ax i l l ar y an d m an d i b u l ar m olar s;
4- Pat ient s w it h a pr eoperat ive pain level fr om 0 t o 25 on t he visual analogue scale ( VAS) of 100 m m lengt h.
Ex clu sion cr it e r ia
1- Palpat ion pain; 2- Br uxism or clenching;
3- Ant ibiot ics or analgesics t aken in t he past 24 h;
4- Pr evious r oot canal t r eat m ent ; 5- Sw elling or sinus t ract ;
6- Sever e per iodont al disease; 7- Pocket dept h gr eat er t han 5 m m ; 8- Mobilit y gr eat er t han grade 1; 9- Per iapical radiolucency; 10- Sever ely dam aged t eet h; 11- Absence of occlusal cont act ;
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1 3 Te e t h w i t h p r o b l e m s , s u c h a s o v e r
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det er m ining w or king lengt h.
The pat ient s w er e random ly dist r ibut ed int o t he gr oups using a w eb pr ogram ( available at w w w. random izer.or g) . Pat ient and gr oup num ber s w er e r ecor ded on paper. Aft er each pat ient signed t he infor m ed consent for m , t he t oot h was anest het ized w it h a local anaest het ic solut ion cont aining 1. 7 m L of 4% ar t icaine w it h 1: 100 000 epinephr ine
( Ult racaineDS® for t e; Avent is, I st anbul, Tur key) . A
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w er e per for m ed. The pr ocedur e was init iat ed 15 m in lat er.
Aft er a st raight - line access cavit y was prepared, t he pr ocedur e was com plet ed under r ubber- dam isolat ion. The working lengt h was det erm ined by an elect ronic apex locat or ( Root ZX m ini; J. Morit a Mfg Cor p., Kyot o, Japan) , and t he Recipr oc inst r um ent s w e r e u se d a cco r d i n g t o t h e m a n u f a ct u r e r ’s inst r uct ions. A new Recipr oc inst r um ent was used for each pat ient . Palat ine canals of m axillary m olars
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The pat ient s w er e divided int o four gr oups ( n= 14) accor ding t o t he kinem at ic m ovem ent s, as follow s: count er clockw ise cont inuous r ot at ion, 360° CCW – 30° CW, 270° CCW – 30° CW, and 150° CCW – 30° CW.
For all gr ou ps, t h e speed of t h e m ot or w as adj ust ed t o 300 r pm . For t he cont inuous r ot at ion
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w as u sed t o m ain t ain ap ical p at en cy. For t h e ir r igat ion, 2 m L of 1.25% NaOCl was used bet w een in- and- out pecking m ot ions w it h safet y t ip needle ( Canal Clean; Biodent , Paj u, Kor ea) appr oxim at ely
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was per for m ed using 1.25% NaOCl and 17% EDTA for 1 m in t o r em ove t he sm ear layer.
Aft er r oot canal pr eparat ion, t he r oot canals
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m at ched single cones and AH Plus sealer ( Dent sply De Tr ey Gm bH, Kon st an z, Ger m any ) . Th e pu lp
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and a nanohy br id com posit e r esin w as inser t ed int o t he cavit y using an incr em ent al t echnique and cur ed for 20 s using a LED light - cur ing unit ( Valo Cor dless, Ult radent , Sout h Jor dan, UT, USA) w it h an out put of 1000 m W/ cm2.
The pat ient s w er e inst r uct ed t o use 400 m g
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t he pain was bearable and infor m ed t o r ecor d t he analgesic int ake on a cust om ized for m , w hich was also used by t hem t o r ecor d any pain exper ience. The follow ing var iables w er e r ecor ded:
Age; Gender ; Toot h num ber ;
Pr eoperat ive pain on t he VAS;
Pr eoperat ive and post operat ive per cussion pain levels on t he VAS;
Pain level on t he 1st, 3r d, 5t h, and 7t h days; Analgesic int ake aft er t he pr ocedur e.
Change in pain was calculat ed at t he relat ed day based on t he pr eoperat ive pain.
St a t ist ica l a n a ly sis
of dat a for r educt ion in pain levels, accor ding t o t he day, r evealed non- nor m al dist r ibut ion. Thus, dat a w er e analyzed using t he Kr uskal- Walis and Man n - Wh it n ey - U t est s f or in t er gr ou p an aly sis ( p= 0.05) . The differ ences in age and pr eoperat ive an d post oper at iv e per cu ssion pain lev els w er e st at ist ically analy zed using one- way ANOVA t est ( p= 0.05) . The differ ences in gender and analgesic int ake were st at ist ically analyzed using a chi- square t est ( p= 0.05) .
RESULTS
Table 1 show s t he dem ographic dat a r elat ed t o age, gender, pr eoperat iv e and post operat iv e per cussion, palpat ion, sw elling, and sinus t ract .
Figur e 2 show s t he r educt ion in pain levels at
dif f er en t t im e in t er vals. Th e Kr u sk al- Walis t est
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at Day 1 ( p< 0.05) , but not at t he ot her t im e periods ( p > 0 . 0 5 ) . Man n - Wh it n ey U t est r ev ealed t h at cont inuous r ot at ion r esult ed in m or e pain at Day 1 t han in r ecipr ocat ing gr oups ( 360° CCW – 30° CW and 270° CCW – 30° C) ( p< 0.05) .
The pr eoperat ive and post operat ive per cussion pain lev els am ong t he gr oups sev en day s aft er t r eat m ent w er e not st at ist ically differ ent ( p> 0.05) .
None of t he pat ient s w er e r efer r ed t o t he clinic w it h sw elling or sinus t rack aft er t he t r eat m ent . Also, none of t he pat ient s needed an unscheduled appoin t m en t . Th r ee pat ien t s in t h e con t in u ou s r ot at ion gr oup, t w o pat ient s in t he 360° CCW – 30° CW gr oup, one pat ient in t he 270° CCW – 30° CW,
and t w o pat ient s in t he 150° CCW – 30° CW gr oup
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differ ences w er e found in analgesic use am ong t he gr oups ( p= 0.761) .
D I SCUSSI ON
Recent ly, Neelakant an and Shar m a4 ( 2015) and Nekoofar, et al.5 ( 2015) evaluat ed post operat ive pain aft er inst r um ent at ion of r oot canals w it h a
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How ever, one m ay ar gue t hat t he differ ent cr oss-sect ion s, speed, k in em at ics, an d sy st em s m ay have had an im pact on t he post operat ive pain. I t is necessar y, t her efor e, t o evaluat e t he effect of pur e r ecipr ocat ing or cont inuous r ot ar y m ot ions using inst r um ent s w it h t he sam e cr oss- sect ions on post operat ive pain. Thus, t he pur pose of t his st udy was t o evaluat e various kinem at ic m ovem ent s on p ost op er at iv e p ain u sin g j u st on e t y p e of inst r um ent , a Recipr oc syst em .
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differ ences w er e found am ong t he gr oups at Day 1 ( p< 0 . 0 5 ) , bu t n ot at t h e ot h er t im e per iods ( p> 0.05) Thus, t he null hypot hesis was par t ially r ej ect ed.
An in t er est in g f in d in g w as t h at con t in u ou s r ot at ion r esult ed in m or e pain at Day 1 t han in t he
r ecipr ocat ing gr oups. Because t her e is no sim ilar st u d y in t h e lit er at u r e, t h is f in d in g can n ot b e com pared w it h t hose of previous st udies. Nekoofar, et al.5 ( 2015) com par ed t he int ensit y and durat ion of post operat ive pain using WaveOne and Pr oTaper Un iv er sal sy st em s, f or in st r u m en t at ion of r oot can als, an d f ou n d t h at post oper at iv e pain w as
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in st r u m en t at ion w it h Pr oTaper Un iv er sal r ot ar y inst rum ent s. Pasqualini, et al.7 ( 2015) evaluat ed t he im pact of r ot ar y and r ecipr ocat ing inst r um ent at ion on p ost op er at iv e q u alit y of lif e an d con clu d ed t h a t r e c i p r o c a t i n g i n s t r u m e n t a t i o n a f f e c t e d post operat ive qualit y of life t o a great er ext ent t han r ot ar y inst r um ent at ion. Relvas, et al.10 ( 2015) and
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d if f er en ce b et w een d if f er en t r ecip r ocat in g an d r ot ar y sy st em s in t er m s of post oper at iv e pain .
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r esult s. How ever, a r ecent r epor t by Neelakant an an d Sh ar m a4 ( 2 0 1 5 ) con cl u d ed t h at Reci p r oc
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of post operat ive pain com par ed w it h One Shape. Shokraneh, et al.12 ( 2016) evaluat ed post operat ive
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and Wav e- One inst r um ent s and concluded t hat
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150° CCW -30° CW
270° CCW -30° CW,
360° CCW -30° CW
Continuous rotation
p value
Age 36.36±12.46 27.07±12.71 29.07±11.77 31.79±9.93 .193
Gender (Female*Male) 5*9 9*5 5*9 7*7 .368
Mean ± SD VAS value of preoperative pain 3.57±9.07 1.79±5.40 1.07±4.00 0.00±0.00 .406
Mean ± SD VAS value of preoperative percussion pain
15.57±24.85 5.86±13.10 9.64±12.98 11.00±12.96 .209
Numbers of patients with preoperative palpation sensitivity
0 0 0 0
-Numbers of patients with preoperative swelling 0 0 0 0
-Numbers of patients with preoperative sinus tract 0 0 0 0
-Number of patients who intake preoperative drugs 0 0 0 0
-Numbers of patients with necrotic pulp 0 0 1 0 .383
Numbers of patients with periapical lesion 0 0 0 1 .383
Numbers of patients who needed analgesics postoperatively
2 1 2 3 .761
Mean ± SD VAS value of postoperative percussion pain
3.71±7.44 0.00±0.00 0.00±0.00 3.64±10.30 .209
Numbers of patients with postoperative palpation sensitivity
0 0 0 0
-Numbers of patients with postoperative swelling 0 0 0 0
-Numbers of patients with postoperative sinus tract 0 0 0 0
-Numbers of patients referred for an unscheduled appointment
0 0 0 0
Figure 2- Change in pain levels according to the days. Change in pain was calculated at the day based on the preoperative pain. Continuous rotation increased pain at Day 1 in comparison with other reciprocating groups (360° CCW - 30° CW and 270° CCW - 30° C)
One gr oup. The r esult s of t he lat t er t w o st udies cor r oborat e our r esult s.
A laborat or y st udy by Ar slan, et al.1 ( 2 0 1 5 ) on t he am ount of apically ext r uded debr is, using
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Accor ding t o t he r esult s of t he st udy by Ar slan, et al.1 ( 2015) , t he 150° CCW – 30° CW and 270° CCW – 30° CW r ecipr ocat ing m ot ions ex t r uded
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( p< 0.05) . I n t his st udy, t he cont inuous r ot at ion result ed in m ore pain at Day 1 t han in reciprocat ing gr oups ( 360° CCW – 30° CW and 270° CCW – 30° C) . Alt hough t he 150° CCW – 30° CW r ecipr ocat ing
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cont inuous r ot at ion in t he laborat or y st udy, in t his
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t he 150° CCW – 30° CW r ecipr ocat ing m ot ions and cont inuous rot at ion. There are several explanat ions for t he differ ences in t he r esult s of t he st udies, t he m ost likely being t he differ ent m et hodologies ( in vivo and in vit r o) em ployed.
CON CLUSI ON
Wit hin t he lim it at ions of t his st udy, cont inuous r ot at ion r esult ed in m or e post operat ive pain at Day 1 t han in r ecipr ocat ing gr oups ( 360° CCW - 30° CW and 270° CCW - 30° C) , and, t her eaft er, no
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