Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. REFERENCES Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium hypochlorite for root canal irrigation.J Endodon 1992; 12: 605-612. Brown DC, Moore BK, Brown CE, Newton CW. An in vitro study of apical extrusionof sodium hypochlorite during endodontic canal preparation. J Endodon 1995;(12): 587591. 3 Turkun M, Cengiz T. The effects of sodium hypochlorite and calcium hydroxide on tissue dissolution and root canal cleanliness. Int Endod J 1997;30(5):335-42. 4. Siquerira JF, Rocas IN, Favieri A, Lima KC. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1%, 2.5%, and 5.25% sodium hypochlorite. J Endodon 2000; 26: 331-334. 5 Guerisoli D, Marchesan M, Walmsley A, Lumley P, Pecora JD. Evaluation of smear layer removal by EDT AC and sodium hypochlorite with ultrasonic agitation. Int Endod J 2002;35: 418-421. 6 Siqueira J, Rocas I, Santos S, Lima K, Magalhaes F, de Uzeda M. Efficacy of instrumentation techniques and irrigation regimens in reducing the bacterial population within root canals. J Endodon 2002;28(3): 181-184. 7 Grigoratos D, Knowles J, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endodo J 2001;34:113-119. 8 Sim TPC, Knowles JC, Ng Y-L, Shelton J, Gulabivala K. Effect of sodium hypochlorite on mechanical properties of dentine and tooth surface strain. Int Endod J 2001 ;34: 120-132. Many types of irrigants have been used, such as 9 Hata G, Hayami S, Weine F, Toda T. Effectiveness of oxidative potential water as a root canal irrigant. Int Endod J 2001 distilled water, concentrated acids, and antimicrobials. ;34:308-317. Unfortunately, numerous studies have been done in 10 Hales J, Jackson C, Everett A, Moore S. Treatment protocol vitro (not in a clinical mode) the relative effectiveness for the management of a sodium hypochlorite accident during endodontic therapy. Gen Dent 2001(May/June): of different irrigants has not been clearly demonstrated 278-281. in clinical usage. Therefore much information is theoretical. Although the major function of an irrigant 11 Rotstein I, Karawani M, Sahar-Helft S, Mor C, Steinberg D. Effect of sodium hypochlorite and EDT A on mercury is to flush debris from the canal, the irrigant may have released from amalgam. Oral Surg Oral Med Oral Pathol Oral Radio Endod 2001 ;92(5):556-565. 181 12 Chang Y-C, Huang F-M, Tai K-W, Chou M-Y. The effect of sodium hypochlorite and chlorhexidine on cultured human periodontal ligament cells. Oral Surg Oral Med Oral Pathol Oral Radio Endod 2001;92:446-50. 13 Grandini S, Balleri P, Ferrari M. Evaluation of glyde file prep in combination with sodium hypochlorite as a root canal irrigant. J Endodon 2002;28(4):300-303. 14 Bradford C, Eleazer P, Downs K, Scheetz J. Apical pressures developed by needles for canal irrigation. J Endodon 2002;28(4):333-335. 18 Spolletic P, Siragusa M, Spoleti M. Bacteriological evaluation of passive ultrasonic activation. J Endodon 2003; 29(1) : 1214. 19 Torabinejad M, Cho Y, Khademi A, Bakland L, Shabahang S. The effect of various concentrations of sodium hypochlorite on the ability of MTAD to remove the smear layer. J Endodon 2003;29(4):233-239. 20 Weber C, McClanahan S, Miller G, Diener-West M, Johnson J. The effect of passive ultrasonic actibation of 2% chlorhexidine or 5.25% sodium hypochlorite ittigant on residual antimicrobial actibiey in root canals. J Endodon 2003;29(9):562-564. 15 Goldsmith M, Gulabivala K, Knowles JC. The effect of sodium hypochlorite irrigant concentration on tooth surface strain. J 21 Short R, Dom SO, Kuttler S. The crystallization of sodium Endodon 2002;28(8):575-579. hypochlorite on gutta-percha cones after the rapid-sterilization technique: an SEM study. J Endodon 2003;29(10): 67016 Walters M, Baumgartner J, Marshall J. Efficacy of 673. irrigation with rotary instrumentation. J Endodon 2002; 28(12): 837-839. 22 Sabins R, Johnson J, Hellstein J. A comparison of the cleaning efficacy of short-term sonic and ultrasonic passive irrigation 17 Filho M, Leonardo MR, Silva LAB, Anibal F, Faccioli L. after hand instrumentation in molar root canals. J Endodon Inflammatory response to different endodontic irrigating so 2003;29(10):674-678. lutions. Int Endod J 2002;25 :73 5 - 73 9. 182