Abstract
Aim:
To evaluate the incidence and severity of postoperative pain following root canal treatment in nonvital pulps with hand and rotary instrumentation techniques in Chhattisgarh population.
Materials and Methods:
Sixty asymptomatic single-canaled nonvital teeth were selected and were divided into two groups of 30 each. Group I: 30 single-canalled teeth were treated in a single visit and prepared with hand file system. Group II: 30 single-canaled teeth treated in a single visit and prepared with K3-rotary file system. Group I and II were divided into two subgroups of 15 each (Group IA, IB and Group IIA, IIB) which were irrigated with 2% chlorhexidine and 5.25% sodium hypochlorite, respectively. The patients were recalled at 24, 48, and 72 h and at 1 week to record the incidence and severity of postoperative pain by using visual analog scale.
Results:
Results showed low incidence and severity of postoperative pain following a single-visit treatment with rotary instrumentation when compared to hand instrumentation technique. No statistical significant difference was observed between the groups at different time intervals, i.e., at 24, 48, and 72 h and at 1 week. The use of recent endodontic techniques and devices reduces the postoperative pain.
Conclusions:
Postoperative pain after root canal treatment ranged from mild to severe and it can happen even after high-standard root canal treatment. There is low incidence and severity of postoperative pain following a single-visit treatment with rotary instrumentation when compared to hand instrumentation technique.
KEYWORDS: Endodontic, pain, pulp
INTRODUCTION
Single-visit root canal treatment has become the treatment of choice due to its advantages when compared to multiple-visit endodontics. It has no risk of bacterial leakage beyond a temporary coronal seal between appointments, immediate familiarity with the internal anatomy, canal shape and contour that facilitates obturation, constant working length, no inter-appointment pain, reduction of clinic time, minimizes fear and anxiety and patient comfort.[1,2]
Reducing the incidence and severity of postoperative pain following one-appointment treatment is based on cleaning and disinfection. A root canal treatment with postoperative pain can result in long-term success, whereas treatment without postoperative pain may result in failure.[3] Various research scholars have done extensive work on vital teeth, but very few studies are conducted on nonvital teeth.[4]
The purpose of this study was to evaluate the incidence and severity of postoperative pain following root canal treatment in nonvital pulps with hand and rotary instrumentation techniques in Chhattisgarh population.
MATERIALS AND METHODS
Sixty asymptomatic single-canaled nonvital teeth with 0–3 mm periapical radiolucency were treated. The individual diagnosis was confirmed by obtaining the dental history, palpation, percussion, radiographic examination, and vitality test. Patients having asymptomatic teeth which do not respond to pulp vitality tests and those with no analgesics or antibiotics being given before clinical procedure were included in the study with informed consent. The treatment and study design were explained to the patients.
Teeth were divided into two groups of 30 each to either hand or rotary instrumentation. The access cavity was prepared and coronal orifices were enlarged up to Gates Glidden No. 3. The working length was determined by Ingle's radiographic method and cross-checked using ROOT ZX (J. Morita, Japan).
The root canals in Group I were prepared with K-files (Mani; Prime Dental Products Pvt. Ltd., Mumbai) using step-back technique. Group I was divided into two subgroups of 15 each (Group IA and IB). In Group IA, canals were irrigated with 2% chlorhexidine (Orasep Elan Pharma Ltd., Mumbai) and canals in Group IB with 5.25% sodium hypochlorite (HYPOSEPT; UPS Hygienes Ltd., Mumbai).
In Group II, the canals were prepared with K3-rotary files (SybronEndo, Mexico) using crown-down pressure less technique. Group II was divided into two subgroups of 15 each (Group IIA and IIB). Canals in Group IIA were irrigated with 2% chlorhexidine and canals in Group IIB with 5.25% sodium hypochlorite.
Canals were subsequently dried with sterilized paper points (Dentsply Maillefer) and obturated by lateral condensation technique with 2% gutta-percha points and AH26 sealer (Dentsply Maillefer) in canals prepared using hand instruments, whereas 6% in canals prepared using rotary instruments. In anterior, the coronal sealing was done with glass-ionomer cement and silver amalgam in premolars. Posttreatment control radiographs were taken.
Visual analog scale (VAS)[5] format with complete demonstration was given to the patients. The patients were recalled at 24, 48, and 72 h. After treatment, patients recorded the incidence and severity of pain experienced during the 7-day period. Postoperative pain was categorized as follows: if a patient reported no or minimum pain and no analgesic required, it was classified as none to slight. If the pain required a mild analgesic, the pain was classified as moderate. If the patient experienced severe pain or requirement of a strong analgesic, it was classified as severe. After 7 days, the patient's record was reviewed and percussion and palpation were performed.
RESULTS
Comparison of both the groups after 24, 48, and 72 h and 1 week is shown in respective tables. Chi-square test and Fisher's exact test were applied to compare the proportion of patients with postoperative pain between groups [Tables 1–5].
Table 1.
Comparison of pain incidence at different time intervals
| Pain | Group I - hand K files | Group II - rotary K3 files | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||||||||
| Group IA -CHX | Group IB - NAOCL | Group IIA - CHX | Group IIB - NAOCL | |||||||||||||
|
|
|
|
|
|||||||||||||
| 24 h | 48 h | 72 h | 1 week | 24 h | 48 h | 72 h | 1 week | 24 h | 48 h | 72 h | 1 week | 24 h | 48 h | 72 h | 1 week | |
| N/S | 11 | 13 (86.7) | 13 (86.7) | 12 (80.0) | 10 (66.7) | 12 (80.0) | 14 (93.3) | 12 (80.0) | 13 (86.7) | 14 (93.3) | 14 (93.3) | 15 (100) | 12 (80.0) | 13 (86.7) | 13 (86.7) | 15 (100) |
| Moderate | 3 (20.0) | 1 (6.7) | 2 (13.3) | 3 (20.0) | 5 (33.3) | 3 (20.0) | 1 (6.7) | 3 (20.0) | 2 (13.3) | 1 (6.7) | 1 (6.7) | - | 2 (13.3) | 1 (6.7) | 2 (13.3) | - |
| Severe | 1 (6.7) | 1 (6.7) | - | - | - | - | - | - | - | - | - | - | 1 (6.7) | 1 (6.7) | - | - |
| Significance, χ2, P | 3.45, 0.75 | 3.33, 0.34 | 2.14, 0.54 | 4.56, 0.60 | ||||||||||||
N/S: None to slight
Table 5.
Comparison of pain incidence at 1 week
| Pain | Group I - hand K files | Group II - rotary K3 files | CHX | NaOCl | ||
|---|---|---|---|---|---|---|
|
|
|
|
||||
| Group IA - CHX, n (%) | Group IB - NaOCl, n (%) | Group IIA - CHX, n (%) | Group IIB - NaOCl, n (%) | Fisher’s exact test | ||
|
| ||||||
| Hand versus rotary | Hand versus rotary | |||||
| N/S | 12 (80.0) | 12 (80.0) | 15 (100) | 15 (100) | P=0.07 | P=0.07 |
| Moderate | 3 (20.0) | 3 (20.0) | - | - | ||
| Severe | - | - | - | - | ||
| CHX versus NaOCl (χ2, P) | 0.00, 1.00 | - | - | |||
N/S: None to slight
Table 2.
Comparison of pain incidence at 24 h
| Pain | Group I - hand K files | Group II - rotary K3 files | CHX | NaOCl | ||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
|||||
| Group IA - CHX, n (%) | Group IB - NaOCl, n (%) | Group IIA - CHx, n (%) | Group IIB - NaOCl, n (%) | Hand versus rotary | Hand versus rotary | |||
|
|
|
|||||||
| χ 2 | P | χ 2 | P | |||||
| N/S | 11 (73.3) | 10 (66.7) | 13 (86.7) | 12 (80.0) | 0.33 | 0.56 | 1.44 | 0.23 |
| Moderate | 3 (20.0) | 5 (33.3) | 2 (13.3) | 2 (13.3) | ||||
| Severe | 1 (6.7) | - | - | 1 (6.7) | ||||
| CHX versus NaOCl (χ2, P) | 1.55, 0.46 | 1.04, 0.59 | - | |||||
N/S: None to slight
Table 3.
Comparison of pain incidence at 48 h
| Pain | Group I - hand K files | Group II - rotary K3 files | CHX | NaOCl | ||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
|||||
| Group IA - CHX, n (%) | Group IB - NaOCl, n (%) | Group IIA - CHX, n (%) | Group IIB - NaOCl, n (%) | Hand versus rotary | Hand versus rotary | |||
|
|
|
|||||||
| χ 2 | P | χ 2 | P | |||||
| N/S | 13 (86.7) | 12 (80.0) | 14 (93.3) | 13 (86.7) | 1.04 | 0.59 | 2.04 | 0.36 |
| Moderate | 1 (6.7) | 3 (20.0) | 1 (6.7) | 1 (6.7) | ||||
| Severe | 1 (6.7) | - | - | 1 (6.7) | ||||
| CHX versus NaOCl (χ2, P) | 2.04, 0.36 | 1.04, 0.59 | ||||||
N/S: None to slight
Table 4.
Comparison of pain incidence at 72 h
| Pain | Group I - hand K files | Group II - rotary K3 files | CHX | NaOCl | ||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
|||||
| Group IA - CHX, n (%) | Group IB - NaOCl, n (%) | Group IIA - CHX, n (%) | Group IIB - NaOCl, n (%) | Hand versus rotary | Hand versus rotary | |||
|
|
|
|||||||
| χ 2 | P | χ 2 | P | |||||
| N/S | 13 (86.7) | 14 (93.3) | 14 (93.3) | 13 (86.7) | 0.37 | 0.54 | 0.37 | 0.54 |
| Moderate | 2 (13.3) | 1 (6.7) | 1 (6.7) | 2 (13.3) | ||||
| Severe | - | - | - | - | ||||
| CHX versus NaOCl (χ2, P) | 0.37, 0.54 | 0.37, 0.54 | ||||||
N/S: None to slight
DISCUSSION
K-files with a triangular cross-section are considered to be the best instruments for cutting dentine in a wet environment. Step-back technique provides more flare at coronal part of the root canal with proper apical stop.[6] Hence, K-files with step-back technique were selected in our study.
In recent years, with the advent of rotary nickel titanium, single-visit endodontics has gained acceptance as the treatment of choice for most endodontic cases. The rotary technique is less fatigue for the practitioner and decreases postoperative pain for the patient, most likely due to combination of file design and crown-down modality. K3 rotary system was selected for the study due to its positive rake angle with a variable core diameter which enhances flexibility. It has excellent cutting ability, better canal geometry, and less canal transportation.[7]
In the present study, 21 of the 30 patients reported no pain, eight had moderate pain, and one had severe pain at 24 h in Group I. 25 of the 30 patients reported no pain, four had moderate pain, and one had severe pain at 24 h in Group II. We found no significant difference in the number of patients who had moderate pain between Group I and II at 24 h. Mattscheck et al.[8] suggested that the pain is not related to the canal contents, but likely due to procedure, in general. The other reason for pain could be due to mechanical, chemical, or microbial injuries to the periradicular tissues, thereby resulting in acute inflammation.
In Group I, 25 out of 30 patients had no pain, four had moderate pain, and one had severe pain at 48 h. In Group II, 27 out of 30 patients showed no pain, two had moderate pain, and one patient had severe pain at 48 h. Group I and II had no statistical significance at 48 h; whereas one patient in each group still suffered with severe pain. Apical extrusion of contaminated debris to the periradicular area can cause pain. A gradual reduction in the number of moderate pain was observed at 48 h in both the groups.
27 of the 30 patients reported no pain; three had moderate pain at 72 h in Group I and II. None of the patients in both the groups experienced severe pain at 72 h. Comparison of pain incidence and severity at 72 h between the groups showed no statistical significance.
At the 7th day evaluation in Group I, 6 patients out of 30 had moderate pain, which was controlled with a mild analgesic; whereas all 30 patients in Group II had no pain at 1 week. Although there was difference in the number of patients having moderate pain, no statistical difference was observed between the groups. Canals prepared with crown-down technique had less postoperative pain when compared to step-back technique in our study. The reason is less amount of debris extrusion periapically which influences the response of the periradicular tissues. Many studies have proven that instrumentation with crown-down technique reduces the probability of flare-ups.[9,10]
We found low incidence and severity of postoperative pain following a single-visit treatment with rotary instrumentation (100%) when compared to hand instrumentation (80%) with nonsignificant difference. The result of this study is similar to the studies done by many authors.[11,12]
VAS may improve pain assessment in those patients who fully comprehend the meaning of the scales. Although often the intensity of pain has a strong influence on how unpleasant the experience of pain is, some subjects are able to experience more pain than others before they feel very bad about it. As the pain threshold level differs from person to person, search for a tool, especially to assess pain, must continue. A long-term evaluation of postoperative pain incidence and severity is recommended with increase in the number of subjects.
CONCLUSIONS
Postoperative pain after root canal treatment ranged from mild to severe and it can happen even after high-standard root canal treatment. There is low incidence and severity of postoperative pain following a single-visit treatment with rotary instrumentation when compared to hand instrumentation technique.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Trope M. Flare-up rate of single-visit endodontics. Int Endod J. 1991;24:24–7. doi: 10.1111/j.1365-2591.1991.tb00866.x. [DOI] [PubMed] [Google Scholar]
- 2.Siju J. Famdent Practical Dentistry Handbook. Vol. 6. San Francisco, CA, USA: Scribd, Inc; 2006. Single visit endodontics; pp. 1–6. [Google Scholar]
- 3.Trope M, Bergenholtz G. Microbiological basis for endodontic treatment: Can a maximum outcome be achieved in one visit? Endod Top. 2002;1:40–53. [Google Scholar]
- 4.Jorge Paredes Vieyra and Julieta Acosta Guardado Endod Pract 2009. Endod Pract. 2009;11(02):27–30. [Google Scholar]
- 5.Arjumand FS, Mohammed MS. Pain after single visit endodontic treatment using fifth generation file systems an in vivo study. Indian J Conserv Endod. 2017;2:107–14. [Google Scholar]
- 6.Nisha G, Amit G. Textbook of Endodontics. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2010. Single visit endodontics; pp. 301–3. [Google Scholar]
- 7.Shafer E, Florek H. Efficiency of rotary nickel-titanium K3 instruments compared with stainless steel hand k-Flexofiles, part 1. Shaping ability in stimulated curved canals. Int Endod J. 2003;36:199–207. doi: 10.1046/j.1365-2591.2003.00643.x. [DOI] [PubMed] [Google Scholar]
- 8.Mattscheck DJ, Law AS, Noblett WC. Retreatment versus initial root canal treatment: Factors affecting post-treatment pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:321–4. doi: 10.1067/moe.2001.115135. [DOI] [PubMed] [Google Scholar]
- 9.Morgan LF, Montogomery S. An evaluation of the crown-down pressureless technique. J Endod. 1984;10:491–8. doi: 10.1016/S0099-2399(84)80207-1. [DOI] [PubMed] [Google Scholar]
- 10.Jose FS, Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28:457–60. doi: 10.1097/00004770-200206000-00010. [DOI] [PubMed] [Google Scholar]
- 11.Michael JJ, Robert RW. A comparison of 20% chlorhexidine gluconate and 525% sodium hypochlorite as antimicrobial endodontic irrigants. J Endod. 1994;20:276–8. doi: 10.1016/s0099-2399(06)80815-0. [DOI] [PubMed] [Google Scholar]
- 12.Isabela NR, Jose FS. Comparison of the in vivo antimicrobial effectiveness of sodium hypochlorite and chlorhexidine used as root canal irrigants: A molecular microbiology study. J Endod. 2011;37:143–50. doi: 10.1016/j.joen.2010.11.006. [DOI] [PubMed] [Google Scholar]
