Reduction of Post-endodontic Pain After 3 Irrigation Regime
Condition: Post-operative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      The goal of this research was to relate the occurrence of post-endodontic pain after
      single-visit RCT using there irrigating regime. Methodology: All 216 patients had upper or
      lower molar, premolar or anterior teeth selected for conventional RCT for prosthetic reasons
      detected with only vital pulps. Of the sample of 216 teeth, were selected to just one method
      for instrumentation and different manner to irrigate. All instruments were used with a micro
      motor (VDW, Munich Germany). Reciproc instruments. Final irrigation with cold (8oC, 2.5 oC
      and room temperature 17% EDTA and saline solution served as a lubricants.
    

Detailed description: 
      Two hundred and sixteen of 245 patients (119 women and 97 men) aged 18-65 years were referred
      and incorporated in this research while 29 were excluded as not meeting the inclusion
      criteria. All patients presented with a vital upper or lower molar, premolar or anterior
      teeth selected for conventional root canal treatment for prosthetic reasons.

      Patients rejecting to join the study or rejecting, single-visit root canal treatment,
      consuming analgesics or NSAIDs were excluded too. All participants were informed on the
      goals, risks and strategy of the study, and written informed consent permissions were gained
      previous their enrollment.

      Random Selection of instrumentation groups. An investigator who had not contributed in the
      study made the randomization arrangement using a computer random table generator
      (www.random.org). Each patient receive a consecutive number. A total of 216 patients met the
      inclusion requirements and were incorporated in the study. Of the sample of 216 teeth, 72
      were randomly assigned to the one of the 3 irrigating methods. Treatment was performed by 3
      experienced endodontists; each prepared 72 teeth, 24 per method.

      Treatment Protocol All patients were anesthetized with two carpules of articaine 2% with
      epinephrine 1:200,000 (Septodont, Saint-Maur des-Fosses, France). In cases in which
      supplemental anesthesia was needed, intraligamental anesthesia (2 mL articaine 2%) was
      administered. For the upper teeth, the 2 carpules were administered by gradual infiltration
      in the buccal vestibule. For the lower teeth, 1.5 of the carpules was used for an inferior
      alveolar nerve block and the other 1.5 for a gentle buccal infiltration around the tooth to
      be treated.

      After absolute isolation using rubber dam, the tooth was disinfected with 5.25% NaOCl.
      Preparation of the access cavity was performed using # 331 bur (Dentsply International, York,
      PA), with high-speed and water cooling. 5.25% NaOCl was used to clean the coronal cavity. The
      root canals were carefully probed with #10 K-type hand files (Flex-R files, Moyco/Union
      Broach, York PA, USA).

      REDTA (Roth International, Chicago, IL) lubricant was located at the entry of the canals.
      Working length was determined with a #15 k-file and the Root ZX electronic device (J Morita,
      Irvine CA, USA), followed by subtracting 0.5 mm from the measurement, which was confirmed
      radiographically (Schick Technologies, NY, USA). Cervical and middle thirds of the root canal
      was flared with a K3XF 25/10 rotary instrument (Kerr Endo, Orange County, CA) at 500 rpm. The
      root canal was irrigated with 3 mL 5.25% sodium hypochlorite (NaOCl). A glide path to the WL
      was the established.

      For mechanical preparations, all instruments were used with a micro motor (VDW Silver Motor,
      VDW, Munich Germany). Torque and rotation were preset for each Reciproc instrument. Rotary
      Ni-Ti instruments were used in continuous reciprocating mode.

      Dentinal debris was eliminated from the file with a gauze, instantaneously to the instrument
      change after 2-3 in-and-out (pecking) movements (Reciproc) following the manufacturers'
      recommendations. Each root canal was irrigated with 2.5mL 2.6% NaOCl. Irrigation was
      performed using a 24-gauge needle (Max-I-Probe; Tulsa Dental, York, PA) and a 31-G NaviTip
      needle (Ultradent Products Inc, South Jordan, UT) when reaching the WL after each instrument
      insertion. A size #10 K file was used to maintain WL after each Reciproc instrument.

      Group A. The R25 (size 25/ .08) instrument was used in thin and curved root canals, and R40
      files (40/ .06) were used in wide root canals. Three in-and-out pecking motions were used
      with an amplitude of not more than 3 mm until reaching the estimated working length. Patients
      assigned to this group receive a final irrigation with 5 mL cold (8oC) 17% EDTA followed with
      20 mL cold (8oC) sterile saline solution delivered to the WL using a cold (8oC) sterile
      microcannula attached to the Endo Vac System (Kerr Endo) for 5 minutes.

      Group B. Canals were prepared as in group A, Patients assigned to this group receive a final
      irrigation with 5 mL cold (2.5oC) 17% EDTA followed with 20 mL cold (2.5oC) sterile saline
      solution delivered to the WL using a cold (2.5oC) sterile microcannula attached to the Endo
      Vac System (Kerr Endo) for 5 minutes.

      Control group (CG). The R25 (size 25/ .08) instrument was used in thin and curved root
      canals, and R40 files (40/ .06) were used in wide root canals. Three in-and-out pecking
      motions were used with an amplitude of not more than 3 mm until reaching the estimated
      working length. Reciproc instruments were used in one tooth only (single use). Patients
      assigned to this control group were treated identically to the experimental groups, except
      that receive a final irrigation with 5 mL (room temperature) 17% EDTA followed with 20 mL
      (room temperature) sterile saline solution delivered to the WL using a sterile microcannula
      attached to the Endo Vac System (Kerr Endo) for 5 minutes.

      After instrumentation, the root canals were irrigated with 1 mL 2.6% NaOCl, agitated
      ultrasonically. Ultrasonic activation was performed using an Irrisafe ultrasonic 20.00 tip
      (Satelec, Merignac, France) at 50% power of the MiniEndo ultrasonic unit (Kerr Endo) with the
      tip placed 3 mm from the working length for 30 seconds per root canal.

      Each experimental and control group received a final irrigation with the irrigant described
      above, to eliminate the smear layer and reduce post-endodontic pain. Caution was taken to
      ensure that the micro cannula would suction correctly by detecting the system's transparent
      evacuation tube. In case there was any obstruction, the micro cannula was instantly
      substituted.

      Recapitulation of working length was performed again by using an apex locator as described
      before using #35 and #40 files.

      The root canals were dried with disinfected paper points and obturated at the same visit.
      Gutta-percha cones (Dentsply Maillefer) were laterally compacted with #20 nickel-titanium
      spreaders (Dentsply Maillefer) and AH-plus as the sealer (Dentsply Maillefer). The access
      cavities of anterior and posterior teeth were etched and repaired with Fuji IX (GC Corp,
      Tokyo, Japan).

      Assessment of Post-endodontic pain and Statistical Analysis After these irrigation regimens,
      the patients were informed of the probable incidence of pain for days following RCT and
      received a survey form (VAS questionnaire) to be finished and returned three days after. In
      it, they proof the presence/absence of post-endodontic pain. The pain level was measured
      using a validated pain scale known as the VAS. The pain VAS is a continuous scale comprised
      of a horizontal line, which is 10 cm in length. For pain intensity, the VAS is anchored by
      ''no pain'' (score of 0) and ''pain as bad as it could be'' (score of 10). The cut points on
      the pain VAS are no pain (0-0.5 cm), mild pain (0.6-4.0 cm), moderate pain (0.45-7.4 cm), and
      severe pain (7.5-10 cm). The pain VAS was completed by the patients. The patients were asked
      to put a mark perpendicular to the pain VAS line at the point that indicated their pain
      severity during the 3 days after the endodontic treatment.

      Two hundred and ten of the 216 surveys were returned correctly returned. Of these, 69
      belonged to the group A, 70 to group B and 71 to the Control group. The missing 6
      questionnaires were returned one day later and were included in the data analysis.

      The outcomes for the groups A, B and CG associated to occurrence (yes/no), level (mild,
      moderate, severe), and interval (days) of post-endodontic pain were evaluated, and related to
      the following diagnostic factors: condition of tooth (all vital), occurrence or nonappearance
      of pre-operative pain, group of teeth (molar/premolar or anterior), or location (Maxillary,
      Mandibular).
    

Intervention name(s): Applied saline solution at 2.5 oC (Cryotherapy group); Applied saline solution at 8oC (Cryotherapy ); Applied saline solution at room temperature (No cryotherapy)
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): Patients assigned to this group will receive a final irrigation (application of cryotherapy) with 5 mL cold (8oC) 17% EDTA followed with 20 mL cold (8oC) sterile saline solution delivered to the WL using a cold (8oC) sterile microcannula attached to the Endo Vac System (Kerr Endo) for 5 minutes.; Patients assigned to this group receive a final irrigation (application of cryotherapy) with 5 mL cold (2.5oC) 17% EDTA followed with 20 mL cold (2.5oC) sterile saline solution delivered to the WL using a cold (2.5oC) sterile microcannula attached to the Endo Vac System (Kerr Endo) for 5 minutes.; Patients assigned to this control group were treated identically to the experimental groups, except that they will receive a final irrigation ( application of irrigant at room temperature) with 5 mL (room temperature) 17% EDTA followed with 20 mL (room temperature) sterile saline solution delivered to the WL using a sterile microcannula attached to the Endo Vac System (Kerr Endo) for 5 minutes.
Intervention MeSH terms: Pharmaceutical Solutions
Allocation: Randomized
Intervention model: Factorial Assignment
Intervention model description: Random Selection of instrumentation groups. Of the sample of 216 teeth, 72 were randomly assigned to the one of the 3 irrigating methods. Treatment was performed by 3 experienced endodontists; each prepared 72 teeth, 24 per technique.
Masking: Double (Participant, Investigator)
Primary purpose: Treatment
Keywords: post-endodontic pain; pain; root canal treatment; cryotherapy