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Pakistan Oral & Dent. Jr. 25 (2) Dec 2005
OPERATIVE DENTISTRY
COMPARISON OF POSTOPERATIVE PAIN — NORMAL SALINE Vs
SODIUM HYPOCHLORITE AS IRRIGANTS
*SHAHID SHUJA QAZI, BDS, MGDS
**MANZOOR AHMED MANZOOR, MCPS, FCPS
***RIZWAN QURESHI, FCPS- II Trainee in Operative Dentistry
***HANNAN HUMAYUN KHAN, FCPS- II Trainee in Operative Dentistry
ABSTRACT
The objective of this comparative analytical study was to compare postoperative pain after use of
normal saline and sodium hypochlorite as irrigants. This study was carried out at Armed Forces
Institute of Dentistry (AFID), Rawalpindi (Pakistan) from April 2003 to August 2004. Total one hundred
patients satisfying the inclusion criteria were selected who cooperated for complete follow up. Presence
of pain and its threshold was checked before and after the root canal therapy using normal saline in
one group and 2.6% sodium hypochlorite in the other group. The overall postoperative pain was less
when only normal saline was used as root canal irrigant as compared with 2.6%s odium hypochlorite
for single visit root canal therapy.
Key words: Endodontic treatment, Single visit endodontics, Normal saline, Sodium
Hypochlorite.
INTRODUCTION
Man does not live by bread alone. In the same way,
the pulp system cannot be cleaned and shaped by
instruments alone.' Important adjuncts are irrigants,
that aid in debridement, lubricants, which facilitate the
negotiation of small canals and desiccants, which aid in
drying before obturation. All vary in relative effectiveness. Along with filing, the second important process
during the root canal debridement (cleaning & shaping)
is irrigation." In theory, files loosen and disrupt materials within canals and remove dentin from the walls as
shavings and then the whole sludge is flushed out with
an irrigant. This process is more theoretical than actual,
irrigants and irrigation are only moderately effective.
The most important factor is
the delivery system of the irrigant and not the solution
per se. 1,3,4
During the past 20 years, endodontists have begun
to appreciate the critical role that irrigation plays in
successful treatment. Successful treatment demands a
protocol to allow efficient cleaning and preparation of
canals to be subsequently filled. Irrigation is an important part of this protocol because it assists in: (a)
removing all organic contents ( substrate for bacteria)
from the root canal system and (b) configuring the
system so that it can be obturated to eliminate the
space where bacteria and its irritants can accumulate
again. In order to get maximum efficiency from the
irrigant, the need for apical patency must be recognized
and one should not be afraid to place instruments
Commandant and Classified Specialist in Operative Dentistry, Armed Forces Institute of
Dentistry, Rawalpindi, Pakistan.
** Classified Specialist in Operative Dentistry, Armed Forces Institute of Dentistry Rawalpindi,
Pakistan. *** AFID, Rawalpindi.
For Correspondence: Maj General Shahid Shuja Qazi, Commandant, Armed Forces Institute of
Dentistry, Rawalpindi, Pakistan Tel: 561-34216, 561-31923.
177
to the apex. Getting the irrigant to the apical
portions of the canals is crucial."
The irrigating agent used should meet the following criteria: (1) it must have anti-microbial properties,
(2) it must aid in the debridement of the canal system,
(3) it should have the ability to dissolve necrotic tissue
and (4) it should be nontoxic to periapical tissues. These
requirements are currently being met with the use of
2.6% sodium hypochlorite (aka Clorox or Javex- FULL
strength NOT- diluted.).7Hypochlorite's antibacterial
action is based upon its effects on the bacterial cell wall.
Once the cell wall is disrupted, the vital contents of the
bacteria are released. The bacterial membrane and
intracellular associated functions cease. Sodium hypochlorite is an effective necrotic tissue solvent. The
contact of the solution with organic debris helps to
eliminate the substrate on which bacteria grows. Clinical
investigations have proven that 2.6 % sodium
hypochlorite has no greater irritating effect than normal
saline solution when properly used as an endodontic
irrigant. Because it fulfills all these requirements, it
remains the irrigating solution of choice in endodontic
treatment. Sodium hypochlorite is adversely affected by
exposure to high temperature, light, air, and the
presence of organic and inorganic contaminants. The
tissue-dissolving ability of 2.6% sodium hypochlorite
remains stable for at least 10 weeks."
molars having poor prognosis with out endodontic
treatment, aged between 18 to 40 years without any
sex discrimination. The treatment sites were free from
any gross pathology. All the teeth included in this study
had completed their root formation with mild to
moderate root curvatures.
The exclusion criteria included second and third
molars either mandibular or maxillary. The teeth,
having malformed or badly curved roots, involved in
any gross pathology, root resorption, extra roots, and
extremely large or short roots were excluded. Female
pregnant patients, patients on antibiotics or corticosteroids treatment, immunocompromised patients, and
patients under 18 years and over 40 years of age were
also excluded from the study. None of the abscessed
tooth was included in this study.
One hundred patients falling in above mentioned
inclusion criteria, requiring non-surgical root canal
therapy, agreed to participate in study. The study was
discussed with the patients and solicited their participation. Consent was obtained from all study participants. These patients were further divided into two
equal groups. In first group of 50 patients endodontic
treatment was completed in one visit while only normal
saline was used as root canal irrigant and in second
group of 50 patients root canal treatment was also
completed in one visits but only 2.6% sodium
Normal saline is an isotonic solution to the body
hypochlorite was used as root canal irrigant.
fluids and is being universally used as an
The following patient factors were also collected:
irrigating material in all the surgical procedures
very effecEndodontic treatment is also a type of whether or not the tooth was vital; if nonvital, whether
surgical procedure, so normal saline is routinely there was PAR (periapical area of radiolucency); radioused here. graphic findings and hygienic status ofthe patient. The
decision to use the normal saline or 2.6% sodium
Keeping the above points in mind, we decided to
hypochlorite during root canal treatment was based
design this study to evaluate the post operative pain
randomly and never on pulpal vitality, clinical sympafter use of both irrigating materials separately during
toms, presence or absence of acuteness, sinus tract or
single visit endodontic therapy.
apical pathosis.
MATERIAL AND METHODS
The study was conducted at Operative Department
of Armed Forces Institute of Dentistry, Rawalpindi. A
total of 100 patients were selected satisfying the inclusive and exclusive criteria, which had their teeth
scheduled for nonsurgical endodontic treatment
The inclusion criteria was patients with both maxillary and mandibular teeth from central incisor to first
178
Each patient recorded the preoperative pain level
by using the Heft Parker visual analogue scale (VAS).
The clinicians were trained in the use of the VAS
instrument by one of the investigators and rehearsed.
Patients were told they could place a mark anywhere
on the horizontal VAS scale. Furthermore, they were
told to use the verbal descriptors as a guide. Each
patient mark was assigned a value between 0 and 170
on the VAS. Patients recorded their preoperative pain
level in the presence of the clinicians to ensure that
they understood the instructions. The clinicians then
recorded the dates and times for the remaining 3 times,
which corresponded to postoperative periods of 12, 24,
and 48 hours. Every patient was given the VAS form,
along with a stamped, addressed envelope for return of
the form after 48 hours. Patients were reminded at 24
hours and again at 48 hours to fill the VAS form and
then return the same.
couple of days after endodontic treatment and the
patients were instructed to avoid mastication / cutting /
incising on the endodontically treated teeth for one
week. They were instructed to maintain optimal oral
hygiene.
Operated patients were examined after 24 hours to
ensure any signs of pain and tenderness. If signs of
tenderness were present, teeth were slightly deoccluded
after due recording. Descriptive statistics of SPSS,
The step-back instrumentation technique and ob- (Statistical Package for Social Sciences) version 10
turation by lateral condensation for the endodontic were used to calculate the frequency of success.
procedure was same in all the teeth under study. All
teeth treated were isolated with a rubber dam, caries RESULTS
excavation done, standard straight line access opening
VAS forms were collected from all patients. In all
achieved and the working length was determined using
these patients root canal treatment was completed in
either intraoperative-scaled radiograph with instrusingle visit. All the results were arranged in table # I
ment inside the canals by using paralleling technique to table # 4 and both groups were compared at each
or by using the Endex apex locator (Osada, Los Ange- interval by using an independent -samples t-test. In
les, CA). During instrumentation the root canals offifty this study teeth were subdivided by preoperative diagteeth were irrigated frequently with normal saline only. nosis into vital (n= 68 ) and nonvital (n=32 ) groups as
In second group, root canals of fifty teeth were irrigated in table # 1.
with 2.6% sodium hypochlorite during instrumentation.
The apices were instrumented by using hand operated
Five patients experienced flare-ups after initial
stainless steel H-files. Preparation was completed appointment that required an extra emergency visit. In
sequentially to a size #30 in all multirooted teeth and up such patients, teeth were reopened, irrigated and kept
to size # 40-70 in other single rooted teeth, 1 mm short
drainage. All these patients were previously irriof the radiographic apex.
gated with 2.6% sodium hypochlorite and according to
the initial diagnosis they had necrotic pulps and acute
After all the canals had been nicely prepared, these
apical periodontitis. Five patients reported pain on
were dried with paper points. For all teeth obturation
mastication, out of these, 3 were irrigated with sodium
was completed in a single visit. The canals were filled
hypochlorite and 2 were treated with normal saline
with paste of endomethasone cement with the help of
during root canal instrumentation, so required delentullo spiral placer. Gutta-percha points were inserted
occlusion.
in canals following lateral condensation technique. The
tapered shape of the canal allowed escape of excess
Out of 100 teeth, 68 teeth had vital pulp while 32
sealer coronally. The cement in the canal sealed the teeth had nonvital and necrotic pulp tissue. Over all
apex as well as all lateral and accessory canals. The post-operative pain was less when only normal saline
excess gutta-percha was seared off, and the access was used for root canal irrigation as compared to 2.6%
cavity was sealed with cavit at the coronal end.
sodium hypochlorite.
Each patient was given a prescription for 400 mg of
As all the patients were initially advised to take
ibuprofen, with instructions to take only after recording analgesics (400 mg ibuprofen) when required but after
the pain on VAS, if needed. Patients were also proper recording on VAS. Over all 25% patients rereminded to fill and return the VAS forms. They were
TABLE #1: NON- VITALITV/VITALITV
instructed to call the clinic if adequate pain relief was
RELATIONSHIP
not obtained with the prescription. Any patient calling
Vital teeth
Non vital teeth
to report pain was seen the same day for evaluation and
treatment, if necessary. A soft diet was advised for a
68
32
179
TABLE #2: VAS PAIN MEASUREMENTS FOR ALL PATIENTS (n = 100)
Irrigant
used
Intervals
Mean
VAS
n
SD
Max
VAS
mark
t
Mean
difference
p
Preoperatively
A
B
50
50
86.46
76.33
+ 50.14
+ 49.88
170
170
0.69
.53
7.89
12 hours
postoperatively
A
B
50
50
25.26
43.24
+ 28.48
+ 35.90
170
170
2.09
.06
15.09
24 hours
postoperatively
A
B
50
50
25.62
34.39
+ 24.36
+ 37.32
170
170
1.28
.26
9.47
48 hours
postoperatively
A
B
50
50
16.51
24.12
+ 25.60
+ 32.24
170
170
1.22
.25
6.23
A= Normal Saline, B= Sodium Hypochlorite
Intervals
Irrigant
used
n
M e a n
VAS
S D
M a x
VAS
mark
t
p
M e a n
difference
Preoperatively
A
B
33
35
73.30
75.93
+ 50.17
+ 54.74
170
170
0.18
.89
2.10
12 hours
postoperatively
A
B
33
35
21.78
43.61
+ 26.47
+ 37.93
170
170
2.78
.04
22.32
24 hours
postoperatively
A
B
33
35
23.05
36.82
+ 22.34
+ 35.67
170
170
1.76
.11
14.75
48 hours
postoperatively
A
B
33
35
14.75
27.02
+ 28.65
+ 32.45
170
170
1.56
.18
11.28
TABLE #3: VAS PAIN MEASUREMENTS FOR VITAL TEETH (n = 68)
A= Normal Saline, B= Sodium Hypochlorite
TABLE #4: VAS PAIN MEASUREMENTS FOR NONVITAL TEETH ONLY (n = 32)
Intervals
180
Irrigant
used
n
Mean
VAS
Preoperatively
A
B
17
15
12 hours
postoperatively
A
B
24 hours
postoperatively
48 hours
postoperatively
Mean
difference
1.19
.27
5.73
170
170
0.08
.92
8.8
+ 28.18
+ 29.17
170
170
0.52
.62
4.82
+ 18.15
+ 19.09
170
170
0.62
.65
5.22
Max
VAS
mark
79.09
73.36
+ 43.23
+ 40.06
170
170
17
15
34.65
43.45
+ 37.03
+ 46.13
A
B
17
15
29.74
34.56
A
B
17
15
17.13
22.35
A= Normal Saline, B= Sodium Hypochlorite
t
p
SD
ported to take analgesics with a significant group
predominance in which only sodium hypochlorite was
used as root canal irrigant
additional properties that aid in cleansing and shaping.
Normal saline is widely used as irrigation material
during general surgery and other surgical proce-
DISCUSSION
dures and have no side effects when absorbed periapically.20,21,22
It is important to note that although sodium hypochlorite is non toxic during intracanal use, it can
cause serious consequences if injected periapically.
Irrigation with this solution should always be performed passively. Treating canals by using apical
patency demands caution while irrigating.11,12 The
syringe should NEVER be locked in the canal. This
is especially important in cases with larger apical
diameters and when using smaller commercial
needles that can be placed within the last few mms of
the canal space. If inadvertent periapical injection
occurs, the consequences can be quite alarming and
painful.13 There generally is an immediate severe
burning sensation often accompanied by very rapid
gross swelling. The condition is best treated with oral
analgesics, antibiotics and by reassuring the patient.14
Wedging of a needle in the canal (or particularly out
of a perforation) with forceful expression of irrigant
(usually sodium hypochlorite) causes penetration of
irrigants into the periradicular tissues and inflammation
and discomfort for patients.15 Loose placement of
irrigation needle and careful irrigation with light pressure or use of a perforated needle precludes forcing of
the irrigating solution into the periradicular tissues.
Sudden prolonged and sharp pain during irrigation
followed by rapid diffused swelling (the sodium
hypochlorite accident) usually indicates the penetration
of solution into the periradicular tissues. The acute
episode will subside spontaneously with time. Initially
there is no reason to prescribe antibiotics or attempt
surgical drainage. Treatment is palliative. Analgesics are
prescribed, and the patient is reas-
sured.16,17,18,19
CONCLUSION
Normal saline can be used safely for root canal
irrigation as there will be no pain if absorbed accidentally in periapical area when compared with 2.6%
sodium hypochlorite with out compromising the post
operative outcome of root-canal treatment.
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