Cryotherapy on Inflammatory Profile and Postoperative Pain Levels in Endodontic Infections
Condition: Apical Periodontitis; Postoperative Pain; Cytokine Levels
MeSH terms: Infections; Periodontitis; Periapical Periodontitis; Pain, Postoperative
Study type: Interventional

Summary: 
      The aim of this study is to evaluate the effects of cryotherapy applications on the
      inflammatory cytokine and collagenase matrix metalloproteinase levels during root canal
      treatment and postoperative pain intensity and incidence. Mandibular premolar teeth of 60
      male patients within the 20-30 years old range, diagnosed with asymptomatic apical
      periodontitis will be included to the study for this purpose. The experimental protocols
      consist clinical and laboratory phases. In clinical phase, procedures of cryotherapy and
      control groups will be applied in 2-visit-root canal treatment. The samples, which were
      collected during root canal treatment, will be subjected to enzyme-linked immunosorbent assay
      (ELISA) analysis in laboratory. Levels of interleukin and inflammatory destructive enzymes
      will be determined in collected samples. During the analysis of visual analogue scale scores,
      the correlation between the changes of the cytokine and proteolytic enzyme levels and
      presence and intensity of pain will be evaluated.
    

Detailed description: 
      Cryotherapy is the reduction of the temperature of living tissues for therapeutic purposes.
      The temperature decrease that will occur as a result of cryotherapy depends on the degree of
      the applied tissue and agent, the application time, and the thermal permeability of the
      tissues and the agent . With the application of cryotherapy in human tissues, it is aimed to
      reduce the temperature of the host cells and control pain.

      There is limited data on the use of cryotherapy, which is widely used in medicine, in the
      field of operative dentistry. It is frequently used after surgical procedures such as
      cryotherapy, periodontal surgery, tooth extraction and implant application, but its first use
      in endodontics is to extend the cold saline solution of during root canal treatment. It has
      been described in laboratory studies that it reduces the external temperature of the root by
      applying it with apical negative pressure irrigation system for 5 minutes following the
      procedures. Following this in vitro study, the efficacy of different cryotherapy protocols in
      reducing pain after root canal treatment was reported by all of the few clinical studies.
      Studies reported that after endodontic treatment of teeth with symptomatic apical
      periodontitis, pain severity decreased after cryotherapy application and the frequency of
      postoperative painkiller use of patients decreased. It was reported that cryotherapy
      application in endodontic treatments of teeth with symptomatic irreversible pulpitis with
      vital pulp reduced postoperative pain severity. A laboratory study performed on extracted
      teeth reported that cryotherapy application reduces the vertical fracture strength of the
      roots, however, comprehensive laboratory and clinical studies evaluating the various physical
      properties of the teeth are required in order to make definitive interpretations concerning
      the clinic and to create a consensus.It has not been fully revealed how and by what mechanism
      intra-canal cryotherapy applications reduce pain. When cold is applied, a decrease in blood
      flow occurs in living tissues; It has been shown that neural receptors are inhibited in skin
      and subcutaneous tissues. Clinical studies report that cold therapy reduces acute
      musculoskeletal pain, muscle spasms, connective tissue strains, nerve conduction time, and
      hemorrhage. Cryotherapy restricts the inflammatory reactions that occur in the damaged area
      by causing vasoconstriction and inhibition of cellular metabolism. Vasoconstriction thus
      causes a decrease in edema and blockage of nerve endings with the decrease in temperature
      leads to a decrease in pain. Although decreasing body temperature also decreases peripheral
      nerve conduction, when it falls below 15 ° C, nerve conduction is completely deactivated.
      Tissue damage that may result from secondary hypoxia is also minimized by slowing down cell
      metabolism. The activities and amounts of destructive enzymes in the tissue are reduced. The
      analgesic effect of cryotherapy is achieved by a combination of reducing the chemical
      mediators of pain and slowing down neural pain signals. In addition, a 50% slowdown in
      metabolism has a positive effect on oxygen diffusion in damaged tissues. How intra-canal
      cryotherapy reduces postoperative endodontic pain has not been fully elucidated yet. When the
      effects of cryotherapy applications on damaged muscle and connective tissues are interpreted,
      a decrease in the amount of inflammatory cytokines is expected in a region where cryotherapy
      is applied. The amounts of inflammatory cytokines and destructive enzymes in periradicular
      tissues were not evaluated after intra-canal cryotherapy.

      Intra-canal cryotherapy stands out as a simple, economical and non-toxic pain control
      technique, although it eliminates the side effects that may be caused by drugs by reducing
      the use of painkillers after the procedure. It is a technique that should be applied rather
      than an alternative, especially for patients who are recommended to avoid painkiller use
      (drug allergy, geriatric population). It consists of washing the root canals with cold saline
      solution for 5 minutes, which can be easily adapted to the endodontic treatment routine. This
      procedure can be applied with negative pressure irrigation systems or endodontic irrigation
      needles used in routine irrigation. It is a more practical and controlled procedure than
      applying an ice pack inside or outside the mouth after the procedure, and it will be applied
      by the physician.
    

Intervention name(s): Distilled water irrigation kept at 2.5°C degree; Distilled water irrigation kept at room temperature
Intervention type(s): Device; Device
Intervention description(s): The use of cold distilled water for final irrigation of root canal system during root canal treatment; The use of distilled water kept at room temperature for final irrigation of root canal system during root canal treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment
Keywords: Endodontics infections; Interleukin; Intracanal cryotherapy