Mowaffaq Al Absi1 , Fayez Hussain Niazi2 , Mustafa Naseem3 , Zahid Iqbal4 , Faheem Khiyani5
1. Operative Dentistry, Senior Registrar, Operative Dentistry Department, Isra Dental Collage, Isra University
2. Operative Dentistry, Assistant Professor, Oral Biology Dept Ziauddin College of Dentistry, Pakistan
3. Dental Public Health, Senior Lecturer Community and Preventive Dentistry Ziauddin College of Dentistry, Pakistan
4. Assistant Professor, Operative dentistry dept, Isra Dental College, Isra University.
5. Dental Public Health, Assistant Professor Dept of Community and Preventive Dentistry, Ziauddin College of Dentistry, Pakistan
Corresponding author: “Dr Mustafa Naseem ” < email@example.com >
How to CITE:
Absi M, Niazi FH, Naseem M, Iqbal Z, Khiyani F. “Inter-appointment Pain During Root Canal Treatment By Comparing The Crown-down And Apical Step-back Techniques”. J Pak Dent Assoc 2014; 23(3):100-105
To compare the frequency of Inter-appointment pain by employing crown-down and step-back technique through visual analogue pain scale at different time intervals.
60 patients were selected and divided in to two groups of 30 each. Group A has been instrumented by crown-down and Group B by step-back technique. Patients reported with inter-appointment pain after 24 hours and after 48 hours.
Data were collected and entered in SPSS version 10 for windows. Mean ± SD were presented for age of the patient and VAS. Male to Female ratio were presented for gender distribution. Chi-squared test were used to compare VAS between the two groups. A p-value of < 0.05 was considered as statistically significant.
After 24 hours occurrence of inter-appointment pain was high in group B than group A but it is not statistically significant. After 48 hours inter-appointment pain was high in group B than group A but it is not statistically significant.
The result of this study shows no significant difference in inter-appointment pain between crown-down preparation technique and step-back technique.
Preparation techniques, step-back technique, crown-down technique, inter-appointment pain.
The relationship between pain and dentistry is frequently portrayed in popular culture as synonymous with situations to be avoided. In fact, poorly controlled dental pain and related anxiety contribute to postponed or cancelled appointments1,2. Dental fear is a major reason given for avoiding dental visits3. Effective control of dental pain improves patient comfort, facilitates the delivery of oral care, decreases anxiety, and may even improve oral health. The aim of root canal treatment is to eliminate bacteria from the canal system in order to create an environment favorable for healing. Current preparation techniques along with disinfectants or medicaments may disrupt the intra-canal microbial environment. However, numerous studies have shown that it is impossible to achieve a bacteria free root canal consistently1-4. Hence, there is concern over the consequences of the presence of the remaining microorganisms in the canal.
It is generally believed that the remaining bacteria can be either eradicated or prevented from recolonizing the root canal system through an inter-appointment medicament such as calcium hydroxide2,5. However, it has been demonstrated that calcium hydroxide consistently fails to sterilize root canals and may even allow regrowth in some cases3,4,6. The presence of cultivable microorganisms at the time of obturation has been reported to impair healing after root canal therapy 7. Certain factors such as preoperative pain2 use of intra-canal medications5,6 and tooth localization may predispose the development of inter and post appointment pain. Mechanical instrumentation is the core method for bacterial reduction in the infected root canal. Various treatment regimens for the relief of pain during endodontic therapy, includes pre-medication relief of occlusion, establishment of drainage, intra-canal and systemic medications. Preparation of root canal systems includes both enlargement and shaping of the complex endodontic space together with its disinfection. A variety of instruments and techniques have been developed and described for this critical stage of root canal treatment. The advantages of conventional hand instrumentation from crown to apex with early coronal flaring include less risk of inoculation of endodontic pathogens in the periradicular tissues, enhanced penetration of irrigant into the root canal system, less extrusion of irrigant solution and furthermore there is less likelihood for a change in the working length measurement during preparation, greater tactile awareness and reduced coronal binding of instruments. On the other hand the step-back technique creates a smoother flow and a tapered preparation from apical to coronal direction. Our study is comparing the inter-appointment pain in vital single rooted teeth by using two classical techniques used for root canal preparation. These techniques are crown-down or step-down and apical step-back. The frequency of pain will be assessed by employing visual analogue pain scale to compare the two groups8. Knowledge on the causes and the mechanisms behind inter-appointment pain is very important for the practitioner to manage this undesirable condition. Inter-appointment emergency, proper diagnosis and active treatment is required for the clinician to overcome the problem. It is therefore important to carry out a study, which can help us in improving our knowledge and skills regarding the precise diagnosis as well as the management of inter-appointment pain. Previous local studies are limited in this regard.
Patients were selected from out-door patients coming to operative dentistry department of Liaquat University of Medical and Health Sciences, Jamshoro.
After taking the inclusion and exclusion criteria into
consideration, detailed history were taken and all necessary investigations were done. Pre-operatively, the tooth could not always be accurately diagnosed as vital or non vital by history taking, clinical and radiographic examination and vitality testing, therefore the gold standards of diagnosis was a presence of bleeding from the pulp chamber and the root canals determined by direct observation after access opening, Cases with non vital pulp were selected in this study.
Two standardized peri-apical radiographs were taken during the treatment, as follows:
2- Working length determination with files in situ. Local Anesthesia has been administered and rubber dam applied for isolation. Adequate coronal access into the pulp chamber was made in order to provide easy access of endodontic instruments to all the walls of the root canals.
This was achieved by using high speed hand piece with a number 2 round bur and tapered fissure bur (Alpha Dental Diamond burs USA Certified ISO 9002) for both crown down and step back technique groups. To achieve the working length we used a distance of 1 to 2mm short of the apex to limit our canal preparations and obturation. According to the size of the image of the tooth on the preoperative radiograph, a file was inserted into each root canal so that it would reach approximately within 2mm of the radiographic apex.
From instrument tip to stopper, this length was measured when in the canal the stopper was rested against a reference point. A working length radiograph was subsequently obtained. Correct working length was obtained by observing the distance between tip of the file and radiographic apex.
Canals have been instrumented using a crown-down in the first group by first flaring the coronal third of each tooth with gates gladden bur No (2-4) (Dentsply, Millefer, Switzerland) while middle and apical third was prepared by hand files (Kerr, Romulus, Mich.) along with irrigant using 5.2% sodium hypochlorite solution and step-back technique in the second group by conventional hand-files on apical and middle third and then the coronal third of each tooth were flared with gates gladden bur No (2-4) (Dentsply, Millefer, Switzerland) along with irrigant using 5.2% sodium hypochlorite solution. The canals dried and the teeth were temporized by temporary filling material cavit (provis, Favodent karl Huber GmbH, Germany) and patient were recalled for next appointment to complete the root canal procedure, in case of severe pain, symptomatic treatment were given.
The patients were assigned into group A or B by envelope method. Group A had their root canals prepared by crown down and group B by step-back. The patients were telephonically accessed to record the pain after 24 hours and 48 hours after the initial treatment. The data were collected on the Performa.
Data were collected and entered in SPSS version 10 for windows. Mean ± SD were presented for age of the patient and VAS. Male to Female ratio were presented for gender distribution. Chi-squared test were used to compare VAS between the two groups. A p-value of <0.05 was considered as statistically significant.
A total of 60 patients required endodontic treatment with vital teeth were included in this study and canals were instrumented using a crown-down and step-back technique. Subjects were equally divided into two groups by using envelope method, for group A, root canals prepared by crown down and group B by step-back. The average age of the patients was 32.83 ± 9.23 years (30.45 to 35.22). The average age of the patients was significantly high in group A than group B (40.50 ± 5.51 vs. 25.17 ± 4.64 p=0.0001). Out of 60 patients, 22(36.7%) were male and 38(63.3%) were female. Proportion of gender was not significant between groups (p=1.00). Regarding maxillary and mandibular tooth location thirty three (55%) maxillary teeth were treated and 27(45%) mandibular teeth were treated.
Comparison of inter appointment pain at 24 hrs and 48 hrs between groups are presented in table 1 . Inter appointment pain at 24 hrs was found in 35% (21/60) patients. In group A (crown down technique), inter appointment pain was only in 23.3% (7/30) patients and in group B (step back technique) in 46.7% (14/30) patients. Rate of inter appointment pain was high in group B than group A but it is not statistically significant (chi-square =3.59; p=0.058). In the other word inter appointment pain was 2.87 times more likely in step back technique (group B) than crown down technique (OR=2.87; 95%CI: 0.95 to 8.69).
At 48 hours, inter appointment pain was observed in 40% (24/60) patients. In group A inter appointment pain was in 40% (12/30) patients and in group B in 40% (12/30) patients. Rate of inter appointment pain was not statistically significant between the group at 48 hours (chi-square =0.0001; p=1.00). In the other word odd ratio is 1 (OR=1.00) its mean pain was equally likely in both groups (OR=1; 95%CI: 0.35 to 2.81).
Comparisons of inter appointment pain at 24 hrs and 48 hrs between groups after stratification of gender, age groups and location were presented in table 2 and 3. Gender and age groups were not effect on pain between groups. In Maxillary teeth, pain was significantly high in step back technique than crown back technique (fisher’s exact test; p=0.04) at 24hours. In mandibular teeth, pain was significant at 24hour while at 48hours it was not significant.
Inter appointment pain was and remains one of the most common problems in endodontic treatment procedure although these in most cases do not last long, but could be a source of embarrassment to the dentist and annoying for the patient. Some studies investigating inter appointment pain have reported an incidence of moderate to severe pain in the range of 15% to 25% 7-9. Studies also have reported frequencies of inter appointment emergencies ranging from 1.4% to 16%1. While in our study discomfort to mild inter appointment pain noted from 35%to 46.7%. In this study the frequency of inter appointment pain has been assessed by visual analogue pain scale to compare crown-down and step-back techniques10. Knowledge on the etiological factors and the mechanisms behind inter appointment pain is very importance for the practitioner to properly prevent or manage this undesirable condition. One of this etiological factor is the preparation techniques and their effect on the amount of the debris being extruded through the apical foramina which plays very important role in the frequency of inter and post operative pain. In this study we have found that after the preparation with crown-down and step-back techniques, the rate of inter appointment pain was high in group B (step-back) than group A (crown-down) but it is not statistically significant. Although the rate of the inter appointment pain was high after using step-back technique and that could be due to the amount of the debris pushed beyond the apex or the technique was not able to produce 100% environment free of microorganism it was not enough to bring the result to the significant level. In comparative study between both technique by the quantitative assessment of canal debris forced periapically instrumentation Ruiz-Hubard EE,et al11 concluded that step-back technique reported to produce more debris apically than crown-down. Ferraz CC, et al12 also have found in their study that apical extrusion of debris and irrigants using two hand and three engine-driven instrumentation techniques were more in step-back as it compare with crown-down technique.
Reddy S, Hicks L13 also they have concluded in their study that crown-down extruded less debris after comparing the debris extruded from the apical constriction using two hand and two rotary instrumentation techniques.
It is well understood that the pain has direct relation with status of the pulp pre operatively and the sign/symptoms. In our study the criteria we have taken were included only Non vital cases and we have found that the inter appointment pain was presented in 35% of the cases within the first 24 hrs and 40 % within 48 hrs but in both it was not significant and the intensity of the pain was noticed to vary from degree of discomfort to mild pain and that does not require any analgesic, it was also observed that the pain disappeared slowly and gradually by the end of the root canal procedure.Walton& Fouad et al14 have found that the frequency of flare-ups or interappointment pain in necrotic pulp cases were significantly high as compare with to vital cases. Naidoff also has discuss briefly how necrotic pulp plays role in the development of antibodies-antigens reaction which lead to cascade of complement system and inflammatory reaction resulting in flare-up or inter appointment pain15. So many studies have founded that the incidence of flare-up is more with non vital pulp as it compare with vital.
As the age of the patients is concern in this study we have found that there is no relation between the age of the patients and the inter appointment pain which means that there was no statistically significant differences observed in different age groups in this study. Eleazer PD, Eleazer KR and Matusow also concluded that there is no significant relationships for inter appointment flare-ups with age3. Several studies also have failed to find any relation between ages and inter appointment pain Walton R, and Fouad A14. In their study have found no relation between flare-up and age of the patients Imura N and Zolo M16 have also concluded the same result. Toosy17 who treated necrotic teeth and found no difference in flare-ups rate of age groups except in those patients who were above 50 year. Kane 18 has found no relationship between post obturation pain and age. The reason could be due to a coronal transportation of the radiographic apex because of secondary cementum deposition with advancing age. This would result in an error of working length determination which could lead to extrusion of debris and inter or post preparation pain. After all in the current study and the above discussed studies we have concluded that there is no scientific evidence indicating that age is risk factor in the development of inter appointment pain.
As far as the relation of the pain to gender is concerned, In this study, we have found no relation between the gender and inter appointment pain which meant that there is no significant relation between gender and inter appointment pain and the reason may be due to the small sample size of patients being assessed in our study. However several studies have shown significant relationship where larger sample size of patients were examined4,19,20.
Morse et al21 , Mulhern et al22, Albashaireh and Alnegrish 2 had similar results that we have found in our study but Fox et al23 and Genet et al20 concluded that the incidence of flare-up in females are more as compare to males.
Although it’s hard to believe that women suffer from psychomatic illness but physicians believe that their pain is directed by their emotional status24. Also the biological differences between genders explain the high incidence of pain in female as it compare to male25. The reasons maybe due to difference in pelvic and reproductive organs which may provide an additional portal of entry of infection in females leading to possible local and distant hyperalgesia26. And the fluctuation in female hormonal levels, which may be associated with changing in the levels of serotonin and nor-adrenaline, causing increase in pain during the menstrual period27,28. Our study has concluded that gender difference and females’ predominance in the frequency of inter appointment pain is more but it is not statistically significant. In this study the frequency of inter appointment pain is more in the mandibular as it compare to maxillary teeth. In mandibular teeth pain was significant at 24 hour while at 48 hours it was not significant.
Kane18 found no correlation of post obturation pain with tooth type and that totally opposite to the result that we have concluded which similar to the result of Walton14, Toosy17, Fox23, Mollar29 and Barnett30 There is possible explanations for more pain in mandibular teeth as it compare to the maxillary teeth and that is the cortical thicker plate of the mandible which may cause accumulation of exudates, causes more pressure as compared to maxilla.
The result of this study shows no significant difference in inter-appointment pain between crown-down preparation technique and step-back technique.
Table I: comparison of inter appointment pain at 24 & 48 hrs between groups.
Table II: comparison of inter appointment pain between groups at 24 hours after controlling gender, age and location of teeth.
Table III: comparison of inter appointment pain between groups at 48 hours after controlling gender, age and location of teeth.
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