The Effect of Triple Antibiotic Paste as an Intracanal Medication With an Anti-Inflammatory Drug on Post-Operative Pain of Asymptomatic Uniradicular Necrotic Teeth (A Double Blind Randomized Clinical Trial).
Phase: PHASE1
Conditions: Asymptomatic Necrotic Teeth
Sponsor: Cairo University

The Effect of Triple Antibiotic Paste as an Intracanal 
Medication with an Anti-Inflammatory Drug on Post-
Operative Pain of Asymptomatic Uniradicular Necrotic 
Teeth (A Double Blind Randomized Clinical Trial). 
 
 NCT02907489 
Document date: 24/1/2018  
 
Protocol 
Submitted to the Faculty of Oral and Dental Medicine-Cairo University 
in partial fulfillment of the requirements for Doctorate Degree in 
Endodontics 
 
By 
Mohamed Omaia Ahmed Salah 
B.D.S, October 6 University, 2009 
M.S.C, Cairo University, 2015 
 
 
Department of Endodontics 
Faculty of Oral and Dental Medicine  
Cairo University  
2018 

2 
 
Section 1: Administrative information 
1. Title 
The effect of triple antibiotic paste as an intracanal medication with an anti-
inflammatory drug on post-operative pain of asymptomatic Uniradicular necrotic 
teeth: a double blind randomized clinical trial. 
2. Trial registration 
Trial registration number NCT02907489 
Trial registration link https://clinicaltrials.gov/show/NCT02907489 
3. Protocol version 
Issue date: 24 January 2018 
4. Funding 
Self-funding. 
5. a. Roles and responsibilities – contributors  
A) Prof. Dr. Maged M. Negm   (N.M.) 
* Professor of Endodontics, Faculty of Oral and Dental Medicine, Cairo University. 
** The senior supervisor. 
***Responsible for implementation and allocation concealments. 
B) Dr. Yousra M. Nashaat    (N.Y.)   
* Associate Professor of Endodontics, Faculty of Dentistry, October 6 University. 

3 
 
**1st assistant supervisor. 
***Primary outcome assessor.  
C) Dr. Nehal Nabil   (N.N.) 
*Lecturer in Endodontics, Faculty of Oral and Dental Medicine, Cairo University. 
**2nd assistant supervisor. 
D) Dr. Amal Sabry Othman    (O.A.) 
* Lecturer in Microbiology, Faculty of Applied Medical Sciences, October 6 
University. 
** 3rd assistant supervisor. 
***Secondary outcome assessor. 
E) Dr. Mohamed Omaia Ahmed Salah    (A.M.) 
* Assistant lecturer in Endodontics, Faculty of Dentistry, October 6 University. 
** Researcher. 
*** Responsible for all clinical procedure in this clinical trial. 
5. b. Roles and responsibilities – committees  
Department of Endodontics, Faculty of Oral and Dental Medicine, Cairo University. 
Section 2: Introduction 
6. a. Background and rationale – description of research question and 
justification for undertaking the trial 

4 
 
Description of research question (PICOTS): 
(P) Population: 
Patients with asymptomatic uniradicular necrotic teeth treated in multiple visits. 
(I) Intervention: 
Triple antibiotic paste with an anti-inflammatory drug (diclofenac potassium 50 mg) 
as intra canal medicaments. 
(C) Control / Comparator: 
Non setting calcium hydroxide. 
(O) Outcome: 
 
Outcome 
measure 
Measuring device 
Measuring unit 
1ry 
outcome 
Pain 
Visual Analogue Scale 
(VAS) 
(Cruz Junior et al. 2016) 
Ordinal 
2 ry 
outcomes 
Intracanal 
bacterial 
reduction 
Bacterial culture 
Colony forming 
units per milliliter 
of blood agar 
medium 
 
(T) Time: 
Dental treatment will be done at baseline and postoperative evaluation of pain 
change will be done after 24, 48, and 72 hour from the end of the first visit.  

5 
 
(S) Study design: 
A double blind, randomized controlled clinical trial. 
 
Justification for undertaking the trial: 
Microorganisms are the main cause for pulp and periapical inflammation and 
disease. The failure to effectively eliminate them and their by-products might result 
in persistent irritation and impaired healing. 
 
Earlier researches placed great importance on the bacterial contamination of the root 
canal as it is a major concern in endodontics. Elimination of microorganisms and 
necrotic tissue from root canal system is essential for successful outcome of 
treatment (Drake et al. 1994). 
Some microorganisms as E. faecalis is able to form a biofilm that helps it resist 
destruction by enabling the bacteria to become a thousand times more resistant to 
phagocytosis, antibodies, and antimicrobials than nonbiofilm producing organisms 
(Distel et al. 2002).  
It is resistant to inter appointment medicaments including calcium hydroxide and 
may also reside in canals as single species without the support of other organisms 
(Orstavik & Haapasalo 1990) and (Haapasalo & Orstavik 1987). 
 It was also reported that this microorganism has the ability under specific conditions 
to infect the whole length of the tubules within 2 days (Orstavik & Haapasalo 
1990). 
 

6 
 
Our challenge as endodontists is to implement methods to eliminate this 
microorganism during and after root canal treatment.  
 
Systemic antibiotics appear to be clinically effective as an adjunct in certain surgical 
and nonsurgical endodontic procedures. Their administration is not without the 
potential risk of adverse systemic effects, such as allergic reactions, toxicity and the 
development of resistant strains of microbes. In addition, the systemic administration 
of antibiotics relies on patient compliance with the dosing regimens followed by 
absorption through the gastro-intestinal tract and distribution via the circulatory 
system to bring the drug to the infected site. Hence, the infected area requires a 
normal blood supply which is no longer the case for teeth with necrotic pulps and 
for teeth without pulp tissue. Therefore, local application of antibiotics within the 
root canal system may be a more effective mode for delivering the drug (Gilad et 
al. 1999). 
 
A successful endodontic treatment is therefore dependent on the initial killing of all the 
bacteria, i.e. those present in the root canal as well as those already penetrated in depth. 
The achievement of microbicidal doses becomes critical in the endodontic environment, 
because in such harsh conditions bacteria may aggregate to form a biofilm or enter a 
stationary phase, thus acquiring a resistant phenotype. Accordingly, in endodontic therapy 
the local use of antibiotics allows the use of the necessary very high concentrations. 
Moreover, some antibiotics like tetracyclines may represent the optimal choice to grant 
long-lasting antimicrobial effects, since they readily attach to dentine and are gradually 
released, retaining their antibacterial activity (Khademi et al. 2006). 
6. b. Background and rationale – choice of comparator 

7 
 
Calcium hydroxide will be used as a comparator because it has been used widely in 
endodontics because of its properties such as high alkalinity (Tronstad et al. 1981), 
anti-bacterial activity (Orstavik et al. 1991; Sjögren et al. 1991; Stuart et al. 1991) 
and the ability to create an appropriate environment that favors hard tissue deposition 
and apical repair (Cvek et al. 1976; Ghose et al. 1987). Also It has been noted that 
general indication of intracanal calcium hydroxide is pulpal necrosis. And several 
studies have found a direct relationship between level of infection and amount of 
post operative pain. (Eleazer & Eleazer 1998; Trope 1991; Mor et al. 1992; Walton 
& Fouad 1992)  
As well as it has been suggested that calcium hydroxide has pain preventive 
properties because of its antimicrobial and tissue altering effects. (Walton et al. 
2003) 
Furtheremore studies have shown that calcium hydroxide has the ability to 
dissolve necrotic tissues alone or may increase the effect of other solvents. This 
suggests that calcium hydroxide would be an effective agent in cleaning and 
disinfecting infected root canals. (Safavi et al. 1985) 
 
7. Objectives 
This trial is aiming to answer a clinical question whether in patients with 
asymptomatic necrotic teeth, the use of triple antibiotic paste as intracanal 
medication with an anti-inflammatory drug, compared to a calcium hydroxide, 
reduce  postoperative pain and intracanal bacteria or not? 
8. Trial design 
Randomized, controlled, double blinded, unicenter, parallel, two-arm, superiority 
trial with 1:1 allocation ratio. 

8 
 
Section 3.a: Methods-participants, interventions, and 
outcomes 
9. Description of study settings 
The trial will be conducted in Endodontic clinic, Faculty of Oral and Dental 
Medicine, Cairo University, Cairo governorate, Egypt. 
  - Dental unit that will be used: Adec 200 U.S.A. 
  - X-ray machine that will be used: ViVi, S.r.I, Italy. 
10. Eligibility criteria 
a- Inclusion criteria : 
1. Subject's age between 18-50 years. 
[To study the effects of intracanal medication on permanent teeth; 
above 18 years to ensure complete root formation to avoid false 
negative response of electric pulp testing as well as below 50 years to 
avoid possibility of root canal calcification with false negative 
response] (O’Keefe 1976, Watkins et al. 2002, DiRenzo et al. 2002, 
Siqueira et al. 2002, Harrison et al. 1981) 
2. Both male and female subjects. 
[To study the effect of different variables on the outcome] (Torabinejad et 
al. 1988; Walton & Fouad 1992; Genet et al. 1987) 
3. Medically free and healthy subjects.  
4. Mandibular and maxillary single rooted teeth.  

9 
 
[Because studies have suggested that postoperative pain is more likely to 
occur in multirooted teeth](Ng et al. 2004; Clem 1970) 
5. Asymptomatic non vital teeth. 
[Non vital because researchers believe that post-operative pain in teeth 
with non-vital pulp are more common than teeth with vital pulp due to 
presence of high level of irritants and infectious agents in pulpal and 
periapical region].(Albashaireh & Alnegrish 1998; Clem 1970; Soltanoff 
1978) 
[Asymptomatic because studies have shown that the presence of 
preoperative pain can significantly increase the possibility of 
postoperative pain] (O’Keefe 1976; Genet et al. 1987; Imura & Zuolo 
1995; Torabinejad et al. 1988) 
b- Exclusion Criteria: 
1. Teeth with acute dentoalveolar abscess.  
[Because it was felt that emeregency management should include incision 
and drainage.] (Ehrmann et al. 2003) 
2. Subjects having more than one tooth that require root canal treatment. 
[To eliminate the possibility of pain referral and false results] 
3. Subjects that have taken analgesic, anti-inflammatory or antibiotic drugs during 
the 10 days prior to the start of treatment. 
      [Because it would alter pain perception by the patients] 
4. Pregnant females. 

10 
 
5. Subjects with systemic diseases who have endocrine diseases, Infectious diseases 
or Psychological disturbance. 
6. Teeth with periodontal disease or pulp calcification. 
7. Subjects taking chronic pain medications. 
[Because it would alter pain perception by the patients] 
 
11. a. Interventions 
 
1. The subjects will be selected from the regular attendees of Endodontic clinic, 
Faculty of Oral and Dental Medicine, Cairo University. 
2. A written announcement will be hold in Endodontic clinic, Faculty of Oral 
and Dental Medicine, Cairo University to inform the attendees regarding the 
trial. 
3. Patient examination will be done including medical history, dental history, 
extra-oral and intra-oral examination to evaluate the patient’s health condition 
and data will be recorded in a diagnostic chart (Appendix no. 1). 
4. All subjects fulfilling eligibility criteria will give an informed consent for 
participation (Appendix no. 3).  
5. Preoperative intraoral periapical radiograph will be taken. (Kodak intraoral 
periapical films speed D, KODAK ) 
6. The teeth will be isolated with cotton rolls, electrical pulp testing will be 
performed using electric pulp tester that will be positioned at the middle third of 
the buccal surface of the tooth to check pulp vitality. 
7. Tooth will be anaesthetized by local anesthesia with a non-disposable metallic 
aspirating syringe using 1.8 ml Mepivacaine HCl 2% - Levonordefrin 1:20000 

11 
 
(Carpule Mepecaine-L, Alexandria Company for Pharmaceuticals and 
Chemical Industries, Egypt). 
8. An access cavity preparation will be performed using round bur size 3 and 
endo-Z bur for deroofing under a continuous irrigation with sterile 
physiologic saline (El Nasr Pharmaceutical Chemicals CO., Abu Zaabal, 
Egypt). 
9. Rubber dam will be placed. 
10. The patency of the canals will be checked using size 15 K-files (MANI, INC., 
Tochigi, Japan). 
11. Working length will be determined using an electronic apex locator (Root ZX, 
J.Morita USA, Irvine, CA) at the"0.5" mark then will be confirmed with 
intraoral periapical radiograph, to be 0.5-1 mm, shorter than radiographic 
apex. (Kodak intraoral periapical films speed D, KODAK ) 
12. The canals will be instrumented to a size 25 K-type file (MANI, INC., Tochigi, 
Japan) without irrigation. 
13. The first pre-chemomechanical bacteriological sample (S1) will be acquired. 
Each root canal will be filled with sterile distilled water using a sterile plastic 
syringe. Then a sterile paper point size 25 will be placed in the canal for 1 
minute. The paper point will be immediately transferred into test tube with 
thioglycolate. 
14. Laboratory Procedures: Samples will be immediately processed in the 
laboratory inside an anaerobic chamber (85% N2, 10% H2 and 5% CO2) (Coy 
Laboratory Products, Grass Lake, MI, USA). The entire 4-mL sample will be 
vortexed for 1 minute. An aliquot of 1 mL will then be diluted in enriched 
thioglycolate broth using 10-fold serial dilutions until 10-4. Each diluted 
sample will be inoculated on a 5% sheep blood CDC anaerobic agar plate with 
vitamin K and hemin (BBL Becton Dickinson de Mexico) and will be 

12 
 
incubated at 37°C for 7 days. Colony-forming units (CFU) for each strain of 
bacteria will be counted using pour plate method. The remaining 3 mL of each 
sample will be incubated under anaerobic conditions. After 7 days, the tubes 
will be assessed for turbidity and digital images of each tube will be captured 
to detect bacterial growth. (Manzur et al. 2007) 
15. Preparation of teeth will be performed using rotary ProTaper Universal 
instruments (Dentsply Maillefer, TN, USA) in an endodontic motor and reducing 
hand piece (X-Smart, Dentsply Maillefer, USA), according to the manufacturer 
instructions. 
 
The following sequence will be used for all groups: 
 
 S1 file will be used to prepare two thirds of estimated working length. 
 SX file will be used to prepare two thirds of estimated working length. 
 S1 file will used to full working length. 
 S2 file will used to full working length. 
 F1 file will used to full working length. 
 F3 file will used to full working length. 
 F4 file will used to full working length. 
 F5 file will used to full working length. 
 
16. The canals will be thoroughly irrigated using 2ml of sterile physiologic saline 
(El Nasr Pharmaceutical Chemicals CO., Abu Zaabal, Egypt) as an irrigant 
between each instrument and the other. 
17. The second bacteriological sample (S2) (Post-chemomechanical) will be 
acquired. Each root canal will be filled with sterile distilled water using a 

13 
 
sterile plastic syringe. Then a sterile paper point matching to the apical 
enlargement size will be placed in the canal for 1 minute. The paper point will 
be immediately transferred into test tube with thioglycolate. 
18. Laboratory procedures will be the same like that done in the first 
bacteriological sample. (Manzur et al. 2007) 
19. At this stage (N.M.) will randomly assign subjects with a 1:1 allocation ratio 
into the following two intracanal medication groups using computer software, 
(Microsoft Excel). 
 
1. Group 1: (control) 
The canal will be filled with calcium hydroxide (Metapex) (META 
BIOMED Co, Chungbuk, Korea) after finishing mechanical preparation 
which will be applied through disposable tips supplied by the 
manufacturer. 
2. Group 2: 
The canal will be filled with triple antibiotic paste after mixing equal 
amounts of it with anti-inflammatory drug diclofenac potassium 50 mg 
(Catafast) (NOVARTIS PHARMA S.A.E., Cairo, Egypt) after finishing 
mechanical preparation which will be applied using K-type hand file 
through counter clockwise motion. 
Material 
Specification 
Composition 
Manufacturer 
Metapex 
Non setting 
Calcium 
Hydroxide with 
Iodoform 
Calcium Hydroxide, 
Iodoform and Silicon oil. 
META BIOMED Co, 
Chungbuk, Korea. 
[270 Osongsaengmyeong1-ro, 
Osong-eup, Heungdeok-gu, 
Cheongju-si, Chungbuk, Korea 

14 
 
/ Tel :043-218-1981] 
http://www.meta-biomed.com 
 
Triple 
antibiotic 
paste 
(TAP) 
Mixture of 
ciprofloxacin, 
metronidazole 
and minocycline. 
Using commercially 
available tablets of 
Ciprofloxacin 
(Ciprofloxacin 500 mg), 
Metronidazole (Flagyl 500 
mg) and Minocycline 
(Minocin 50 mg). Following 
the removal of the enteric 
coating of the tablets, the 
contents were ground using 
a mortar and pestle and 
mixed in an equal amounts 
by weight (1:1:1) in a 
mixing pad (100 mg of 
each) and then will be 
dissolved in 100 mL of 
sterile water to prepare 1 
mg/mL solution of TAP 
(Takushige et al. 2004) 
Flagyl 500 mg: (Sanofi 
Aventis, Cairo,Egypt) 
3, El Massaneh St. Zietoun, 
Cairo, Egypt 
Tel.: +202 22860000 
22860060/1/2 
www.sanofi.com 
 
Ciprofloxacin 500 mg: (Amriya 
pharm, Alexandria, Egypt) 
Alexandria-Cairo Desert Rd. 
Km 25, Amriya, Alexandria, 
Egypt. 
Tel.: +20 (3) 470-1001 / 470-
1151 / 470-1146 
http://amriyapharm.com/ 
 
Minocin 50 mg: (Sedico, Giza, 
Egypt) 
1st. industrial zone,6th of 
October City, Giza, Egypt 
Tel: +202-38200575/78/90 
http://www.sedico.net 
 
Catafast 
50 mg NSAIDs 
granules for oral 
solution 
Every sachet contains 50 
mg diclofenac potassium, 
Potassium hydrogen 
carbonate, mannitol; 
NOVARTIS PHARMA S.A.E., 
Cairo, Egypt 
[El Sawah St. – EL Amiria, 
Cairo, Egypt] 

15 
 
(Diclofenac 
potassium) 
aspartame, saccharin 
sodium, glyceryl 
dibehenate, mint flavor, 
anise flavor. 
Tel: +20 2 24567200 
https://www.novartis.com.eg/ 
 
 
20. A cotton pellet will be placed in the pulp chamber and the access cavity will 
be sealed with a temporary filling Orafil-G (Prevest Denpro, Digiana, India). 
21. Postoperative pain will be assessed with a visual analog scale at 24 hours, 48 
hours, and 72 hours after the procedures. The VAS consisted of a 100 mm 
horizontal ruler with no numbers except a 0 at the first part of the scale and a 10 
in the last part of the scale. The patients will be asked to mark the point that was 
equivalent to their pain perception with 0 indicating no pain and 10 indicating 
extreme pain. 
22. The pain levels will be classified as no pain (0), mild pain (1-3), moderate pain 
(4-7) or severe pain (8-10). Additionally the need for analgesics will also 
recorded by the patients on their cards (Appendix no. 2). 
 

16 
 
23. After 72 hour the patient will return for the second visit in which the intracanal 
medication will be removed by irrigation using sterile physiologic saline (El 
Nasr Pharmaceutical Chemicals CO., Abu Zaabal, Egypt). 
24. The final bacteriological sample (S3) will be acquired. Each root canal will 
be filled with sterile distilled water using a sterile plastic syringe. Then a 
sterile paper point matching to the apical enlargement size will be placed in 
the canal for 1 minute. The paper point will be immediately transferred into 
test tube with thioglycolate. 
25. Laboratory procedures will be the same like that done in the first 
bacteriological sample. (Manzur et al. 2007) 
26. Periapical radiograph (Kodak intraoral periapical films speed D, KODAK) will 
be taken with the master gutta percha ProTaper cone #F5 (Dentsply Maillefer, 
TN, USA) for master cone verification. 
27. Obturation will be done in the 2nd visit by single cone technique using ProTaper 
gutta percha points size F5 (Dentsply Maillefer, TN, USA) and ADseal resin 
sealer (META BIOMED Co, Chungbuk, Korea). 
28. A cotton pellet will be placed in the pulp chamber and the access cavity will 
be sealed with a temporary filling Orafil-G (Prevest Denpro, Digiana, India). 
29. Postoperative intraoral periapical radiograph (Kodak intraoral periapical films 
speed D, KODAK) will be taken. 
 
11. b. Interventions-modifications 
No protocol for discontinuation of the procedure. 
11. c. Interventions-adherence 
Face to face adherence session during the first visit will take place to stress on the 
way and the importance of filling the pain diary chart. 

17 
 
As well as phone calls will be given to the subjects to stress on the importance of 
pain diary chart and to remind them with it.  
 
12. Outcomes 
1ry outcome: Post-operative pain change. 
Measuring device: Visual analogue scale (Cruz Junior et al. 2016). 
Measuring unit: Ordinal. 
VAS consisted of a 100 mm horizontal ruler with no numbers except a 0 at the first 
part of the scale and a 10 in the last part of the scale. 
 
0 
No pain. 
1-3 
Mild pain. 
4-7 
Moderate pain. 
8-10 
Severe pain. 
 
2ry outcome: Intracanal bacterial reduction of each strain of bacteria. 
Measuring device: Bacterial culture. (Manzur et al. 2007) 

18 
 
Measuring unit: Colony forming units per milliliter of blood agar medium. 
13. Participant timeline 
Activity 
-1 
Week 
Before 
preparation 
After 
preparation 
After 
(24 
hour) 
After 
(48 
hour) 
After 
(72 
hour) 
Allocation 
√ 
 
 
 
 
 
Randomization 
 
 
√ 
 
 
 
Post-operative 
pain assessment 
 
 
 
√ 
√ 
√ 
Intracanal 
bacterial 
reduction 
assessment 
 
√ 
S1 
√ 
S2 
 
 
√ 
S3 
 
14. Sample size 
The aim of this study is to assess the effect of triple antibiotic paste as an intracanal 
medication with an anti-inflammatory drug on post-operative pain of asymptomatic 
uniradicular necrotic teeth. Prior data by Johns et al., 2014 indicated that the 
probability of success among conventional is 0.35 (successful treatment based on 
strict criteria was defined as absence of pain). If the true probability of success 
among intervention group is 0.65, we will need to study 42 case patients and 42 
control patients to be able to reject the null hypothesis that the exposure rates for 
case and controls are equal with probability (power) 0.8. The Type I error probability 
associated with this test of this null hypothesis is 0.05.  We will use an uncorrected 

19 
 
chi-squared statistic to evaluate this null hypothesis. The sample size was calculated 
by G power program.  
15. Recruitment 
The subjects will be recruited from the regular attendees of Endodontic clinic, 
Faculty of Oral and Dental Medicine, Cairo University to meet the target sample 
size. 
 
Section 3.b: Methods-assignment of interventions 
16. a. Allocation-sequence generation 
(N.M.) will randomly divide participants into two groups with a 1:1 allocation ratio 
using computer software, (Microsoft Excel). 
16. b. Allocation-concealment mechanism 
*All subjects who give consent for participation and fulfil the eligibility criteria will 
be randomized. 
**Number for each member in each group will be written by indispensable pen on 
large white paper sheet. The sheet will be folded eight times and saved inside opaque 
well sealed envelope. 
16. c. Allocation-implementation 
(N.M.) will be responsible for allocation sequence generation and dividing patients 
into three groups. 
 
 
 

20 
 
17. Blinding 
The study will be double-blind in which the patient will not know which intracanal 
medication he /she will receive, and the assessor will be blinded to the intervention 
and the comparator applied on the patients, Only the operator knows the type of the 
intracanal medication used. 
N.Y. will be responsible for primary outcome assessing (post-operative pain 
outcome), while O.A. will be responsible for secondary outcome assessing 
(intracanal bacterial reduction outcome). 
Both the pain diary and microbiology sheet will not contain name of the patients or 
the type of intervention used to ensure blinding and to avoid bias. 
Section 3.c: Methods-data collection, management, and 
analysis 
18. a. Data collection method 
The operator will obtain baseline data through a paper based case report form for 
diagnostic data, medical and dental history. (Appendix no. 1) 
The obtained data for postoperative pain assessment will be recorded in pain diary 
by the patient. (Appendix no. 2) 
18. b. Data collection method-retention 
*Primary outcome will be assessed by the 1st assistant supervisor (N.Y.) through 
pain diary of visual analogue scale (Appendix no. 2) which will be filled by the 
subjects at 24, 48 and 72 hour after 1st visit to be delivered to the operator at the 2nd 
visit. 

21 
 
**All subjects will be given a phone call before the 2nd visit not to forget the pain 
diary. 
***Secondary outcome will be assessed by the 2nd assistant supervisor (O.A.) 
through microbiological analysis of the paper point taken before (S1) and after 
mechanical preparation of the tooth (before placement of the intracanal medication) 
(S2) as well as after removal of the intracanal medication (after 72 hours) (S3) and 
will be done in Microbiology laboratory of Faculty of Dentistry of October Six 
University and then data will be recorded in appendix no. 4. 
19. Data management 
*All data will be entered electronically.  
**Subjects files will be stored in numerical order and stored in secure and accessible 
place and will be maintained in storage till completion of the study. 
20. Statistical methods 
Data will be analyzed using IBM SPSS advanced statistics (Statistical Package for 
Social Sciences), version 21 (SPSS Inc., Chicago, IL). Numerical data will be 
described as mean and standard deviation or median and range. Categorical data will 
be described as numbers and percentages. Data will be explored for normality using 
Kolmogrov-Smirnov test and Shapiro-Wilk test. Comparisons between two groups 
for normally distributed numeric variables will be done using the Student’s t-test 
while for non-normally distributed numeric variables will be done by Mann-Whitney 
test. Comparisons between categorical variables will be performed using the chi 
square test. A p-value less than or equal to 0.05 will be considered statistically 
significant. All tests will be two tailed. 
 
 

22 
 
Section 3.d: Methods-monitoring 
21. Data monitoring-formal committee 
There is no data monitoring committee for this trial due to minimal risks and short 
duration of the trial. 
22. Harms 
Adverse effects are minimal or rare. However, if any harm is seen in the subjects 
both in intervention or control groups it will be recorded, reported and documented 
at the end of the trial. 
23. Auditing 
Auditing of the study design will be done by the Evidence Based Committee – 
Faculty of Oral and Dental Medicine – Cairo University. The audits will review the 
processes of participant enrolment, consent, eligibility, allocation to study groups 
and adherence to trial interventions and policies to protect participants. 
 
Section 4. Ethics and dissemination 
24. Research ethics approval 
This protocol and the template informed consent form (Appendix no. 3) will be 
reviewed and approved by the Ethics Committee of Scientific Research - Faculty of 
Oral and Dental Medicine – Cairo University. 
 

23 
 
25. Protocol amendment 
Any modifications to the protocol which may impact the conduct of the study, 
potential benefit of the patient or may affect patient safety, including changes of 
study objectives, study design, sample sizes or study procedures will require a formal 
amendment to the protocol. Such amendment will be agreed upon by the Ethics 
Committee of Scientific Research and the council of Endodontic department. 
26. Consent 
Researcher will discuss the trial with all subjects. Subjects will then be able to have 
an informed discussion with the researcher. The Researcher will obtain written 
consent from all subjects willing to participate in the trial. All information sheets and 
consent forms have been translated into Arabic. (Appendix no. 3). 
27. Confidentially 
All study-related information will be stored securely. All participant information 
will be stored in locked file cabinets in areas with limited access.  All laboratory 
specimens, reports, data collection, process, and administrative forms will be 
identified by a coded file and each file containing patient’s database including name, 
age, sex, identification number, address, phone number, work address and any other 
personal identifiers and won’t be released outside the study without written 
permission of the participant. 
28. Declaration of interests 
There is no conflict of interests. 
 

24 
 
29. Access to data 
All principal contributors will be given access to the data sets. All data sets will be 
password protected. To ensure confidentiality, data dispersed to project team 
members will be blinded of any identifying participant information. 
30. Ancillary and post-trial care 
All patients will receive postoperative instructions. 
Post-trial care will include referral of the subjects to Operative or Fixed 
Prosthodontics clinic in Faculty of Oral and Dental Medicine Cairo University for 
fixed restoration placement after completion of the root canal treatment. 
31. Dissemination policy 
Study results will be published internationally as partial fulfillment of the 
requirements for PhD degree in Endodontics. 
32. Appendices 
Appendix no. 1: Diagnostic chart. 
Appendix no. 2: Pain Diary.  
Appendix no. 3: Patient consent “in Arabic” 
Appendix no. 4: Microbiology Sheet. 
 
 
 
 

25 
 
Diagnostic Chart 
Chart No:                            
Patient No: 
Date:                                                                            
Dr Name:    
                          
Personal information 
Patient name:                                                         
Gender:  
Patient age: 
Marital status: 
Phone no.: 
Address: 
Occupation:  
 
Medical history         
 
YES 
NO 
Hypertension 
 
 
Hypotension 
 
 
Diabetes 
 
 
Anemia 
 
 
Cardiac disease 
 
 
Bone disease 
 
 
Liver disease 
 
 
Kidney disease 
 
 
Sexual disease 
 
 
Hereditary disease 
 
 
Past surgeries 
 
 
Epileptic 
 
 

26 
 
Others.-----------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------
---------- 
Past dental history 
Extraction ______________________________________________________________   
Endodontic treatment_____________________________________________________ 
Filling   (f): _____________________________________________________________     
Orthodontic treatment______________________________________________________   
Prosthetic treatments ______________________________________________________                
Periodontal treatment ______________________________________________________   
Surgical treatment ________________________________________________________ 
 
Extra oral examination  
--------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------- 
Intra oral examination  
--------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------- 
Patient chief complain-----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------- 
 
 
 

27 
 
Pain Scale Chart 
 
Operator name: ………………………         Operator telephone number: …………………. 
 
Patient number: …………….     Age: …………………..    Sex: …………………… 
  
Please put mark in the following scale to indicate severity of the pain with zero 
indicating no pain and 10 indicating severe pain. 
 
(1) Patient training:                                                                                 
 
(2) After 24 hours 
(Tommorow)    
    
 
                                                                                           
                 
                        
 
 
 
 
 

28 
 
(3) After 84 hours (after 2 days)     
      
                                               
 
 
                    
 
(4) After 27 hours (after 3 
days)                                                                                                                  
    
                     
 
o Did you need to take analgesic? ................................ 
o When you took the first tablet of the analgesic? .................. 
o  Date:  /  /       
o Patient Signature: ………………….. 
 
 
 
 
 

29 
 
Microbiology Sheet 
Operator name: ………………………         Operator telephone number: …………………. 
 
Patient number: …………….     Age: …………………..    Sex: …………………… 
 
 
 
o Date:  /  /       
o Supervisor Signature: ………………….. 
o
 
 
 
 
 
 
Type of 
bacteria 
Bacterial count  
in S1 
Bacterial count 
in S2 
Bacterial count 
in S3 
1.  
 
 
 
2.  
 
 
 
3.  
 
 
 
4.  
 
 
 
5.  
 
 
 
6.  
 
 
 
7.  
 
 
 

30 
 
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31 
 
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456. 

32 
 
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33 
 
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