Abdul Qadir Dall*, Ismail Sheikh**, Noor Ahmed Khoso***
- Lecturer, Dept of Operative Dentistry,. Faculty of Dentistry, Liaquat University of Medical & Health Sciences Jamshoro, Hyderabad.
- Associate Professor & Head, Operative Dentistry Department, Altamash institute of Dental Medicine, Karachi.
- Assistant Professor & Head, Dept. Of Oral Pathology, Faculty of Dentistry, Liaquat University of Medical & Health Sciences, Jamshoro, Hyderabad.
Correspondence: “Dr. Abdul Qadir Dall ” <email@example.com>
How to CITE:
J Pak Dent Assoc 2010;19(3): 148 – 154
Whether root canal treatment (RCT) is performed in single or in multiple sessions, infection control and elimination or reducing postobturation pain is a key factor for the success of RCT. Single visit RCT is now being considered as a good alternative to multiple visit RCT.
The objective of this study was to assess the frequency of post-obturation pain after single visit root canal treatment in teeth with pulpal necrosis along with the effect of age, gender and arch on pain severity after single visit endodontics.
A total of 70 pulpally necrosed teeth of patients requiring RCT were treated at Operative Department of Altamash Institute of Dental Medicine, Karachi; from July 2008 to Feb 2009. 7 patients did not return for followup, therefore 63 patients were included in the study. The study design was Interventional Quasi experimental. Pre and Postobturation pain was recorded according to verbal rating scale before RCT, after 1st day, one week and after one month. Data was analyzed using the Chi-square test.
Preoperative pain was observed in 57% of patients. While at first day follow up, postoperative pain was observed in 58% of patients. After seventh day pain existed in 14% (p=0.0001) of patients, after one month 8% (p=0.0001) patients remained painful. There was significant difference in severity of post-obturation pain in 16 to 35 year age group as compared to 36 to 40 year age group Severity of pain significantly decreased in 16 to 25 and 26 to 35 age group at 1st, 7th and 1 month recall (p=0.001). Male gender in contrast to female gender had a significantly reduced severity of pain 1st month post operatively(p=0.001). Severity of pain was significantly decreased in maxillary teeth as compared to madibular arch (pre vs. 1 days p=0.006) and (1st day vs. 1st month; p=0.0001).
The lack of post-obturation pain was found to be positively co-related with single visit endodontics in age group of 16-35 years, male gender and maxillary teeth.
For many years multiple visit root canal therapy has remained the treatment of choice in dental clinical practice. It is the mode of treatment in which teeth are treated in more then one visit to eliminate or decrease root canal infection. The work of Noyes and Naidorf about the biological versus the technical principles in dentistry gave birth to a new concept about management of Root Canal Therapy (RCT).1 According to Noyes dentists are not inclined to think in biological terms, but they mainly focus on the mechanical aspect. But Naidorf appreciated both the biological and technical aspect achieved by the dentists. This historical debate on biological versus technical aspect basically has changed the way root canal treatment was conceived and practiced. This debate ultimately led to the adoption of single visit treatment by many endodontists and created two schools of thoughts in endodontics. In recent years, single visit RCT has gained increased acceptance as the best treatment for many cases including that of teeth with pulpal necrosis due to certain benefits such as being more economical and convenient for both the patients and dentists.2 Studies in recent literature have shown little or no difference in quality of treatment, incidence of post treatment pain or success rates between single visit and multiple visits RCT. According to some authors single visit RCT has a 6.3% higher healing rate than multiple visits RCT.3
From biological view point the advocates of multiple visit approach claim, that simple instrumentation and irrigation of the pulp space is not sufficient to remove bacterial load and canal contamination. If the canal is left empty microorganisms may multiply rapidly in few days. They believe that the bacteria remaining after chemo-mechanical preparation, can be eliminated or be prevented from repopulating the root canal space by placing an interappointment medicament4,5 and obturation should be postponed till bacterial load considerably decreases6 other wise there will be increased chances of postobturation pain and swelling.7
For the followers of single visit RCT bacterial entombment is an important measure in RCT procedure whether teeth are vital or nonvital (necrosed). They advocate that remaining microorganisms can be harmless if they are entombed in a root filling, immediately after preparing and irrigating the canal space in the same visit. This way, the remaining microorganisms may be killed by the antimicrobial activity of the sealer or the Zn ions of gutta-percha.8 There are, however, situations that require more than one visit like acute symptomatic apical periodontitis or weeping canals which are difficult to dry or due to time constraints etc. Most of the clinicians hesitate to treat patients in single visit due to the fear of increased postobturation pain in necrosed teeth and prefer multiple visits RCT although it is documented in literature that 1.3-50% pain is also associated with multiple mode of RCT.2,9
There is no scientific evidence of increased post operative pain in single visit RCT, as compared to multiple visits RCT.10,11 Therefore the aim of this study was to assess the frequency of pain in endodontic cases with pulpal necrosis treated in a single visit and also along with the effect of age, gender and arch on pain severity after single visit endodontics.
The study was conducted in Operative Department at Altamash Institute of Dental Medicine, Karachi; during July 2008 to Feb 2009. The study design from Interventional Quasi experimental. Non probability
Purposive sampling technique was used to select seventy (70) patients with clinically diagnosed necrosed teeth. Patients having anterior and premolar teeth with necrosed pulps, between the ages of 16 to 40 of either gender were included. The exclusion criteria included previously, RCT treated, acute irreversible pulpitis with vital pulp tissues, root resorption, malposed teeth and severe periodontal problems. The patients who fulfilled all the inclusive criteria were selected for this study from the out patient department of Altamash Institute of Dental Medicine. The procedure and risk benefit of single visit RCT were explained to every patient and an informed written consent was taken before the commencement of RCT procedure.
After the medical and dental history, dental examination was performed and documented. Pulp necroses was determined on the basis of thermal pulp testing. Cold test was performed with ethyl chloride spray (IG-Sprutechnik GMBH Germany) and heat test with the help of heated gutta percha stick. Beside thermal testing periodontal status was also examined through probing, percussion, palpation and examination of the preoperative periapical radiograph. The presence or absence of hemorrhage from the pulp chamber after access opening was used as further confirmation of pulp necrosis. Presence of preoperative pain intensity was recorded according to Verbal Rating Scale (VRS) (table no 1).12
Pretreatment, working length determination (with files in situ), and post obturation periapical radiographs were taken during the procedure of single visit RCT. After getting straight line access opening, estimated working length was taken 1 mm short of the radiographic apex with first binding file (K-type file, Dentsply Malleifer, USA). Manual stepback technique was used to prepare the canals and irrigated with 2.5% sodium hypochlorite. Master apical file was determined by increasing two sizes of first binding file. Paper points were used to dry the canal after the preparation of the root canal, prior to obturation of the tooth. The canal obturation was carried out by standardized gutta percha points. Calcium hydroxide based sealer (Sealapex, Sybronendo) was applied with lentulo-spiral into the canal. Obturation was done by cold lateral condensation. The access cavity was sealed and filled with glass ionomer cement and checked for any interference with articulating paper.
The patients were scheduled to recall at three specific post operative periods of 1st day, 7th day and 30th day. At each post operative recall, the patients were evaluated to determine whether or not there was pain after obturation. The level of pain was recorded on the VRS and patient’s
response was documented.
The statistical package for social science (version 11.0, SPSS Inc., Chicago, IL, USA) was used to analyze data. Evaluation of the frequency of pre and post operative pain was determined by Verbal Rating Scale as: yes (VRS ranging from 1 to 3) and no (VRS = 0), and the intensity of pain considered was the highest score recorded (1=mild, 2=moderate and 3 severe) over the evaluation period. Frequency and percentage of the following clinical factors were also computed like gender, age groups and location of teeth of the patients. Mean with standard deviation, 95% confidence interval, median with IQR were computed for age. Mc-Nemara test was used to compare pre and post operative pain (at 1st day, 7th day and at 1st month). Marginal homogeneity test was also applied to compare severity of pre and post operative pain with respect to follow-up. P≤0.05 was considered as the level of significance
Sixty three (63) patients responded to recall out of seventy, therefore the recall rate was 90%. The average age of the patients was 29.32 ± 9.18 years (fig. 1).
Most of the patients (68.84%) were between 16 to 35 years of age (table no 2).
Out of 63 patients, 32(51%) were male and 31(49%) were female (fig. 2).
Seventy one percent (71%) maxillary teeth were treated and 29% mandibular teeth were treated in this study Fig. 3). Teeth wise distribution is as given in table no 3
Preoperative pain was observed in 57.1% (36/63) patients, whereas it was not observed in 42.9% (27/63) patients (Table no 4)
While at first day follow up, postoperative pain was observed in 58% (36/63) patients P=0.034 (table-1). Postoperative pain after seven days was observed in 14% (9/63) patients and there was no pain in 86% (54/63) patients (P=0.0001). After one month significant reduction of postoperative pain was observed in 92% (58/63) patients after treatment, p=0.0001 (table no 4). Comparison of severity of postoperative pain based on visual rating scale, in single visit root canal treatment in necrosed teeth is presented in table no 5
Preoperative mild pain(VRS 1) was observed 20(31.7%), moderate pain(VRS 2) in 7(11.1%) and severe pain(VRS 3) was observed in 9(14.3%) patients while after day one post-obturation mild pain(VRS 1) was observed in 15(23.8%), moderate pain(VRS 2) in 8(12.7%) and severe pain(VRS3) was observed in 4(6.3%) patients. After one month severe pain(VRS 3) was observed only in 1(1.6%) patient and mild pain(VRS 1) was in 4(6.3%) patients while moderate pain(VRS 2) was observed in none of the patients.
Severity of pain significantly decreased in 16 to 25 and 26 to 35 age group at 1st, 7th and 1 month recall while reduction in severity of pain was not statistically significant in 36 to 40 years of age at 1st and 7th day recalls (table no 6).
Effect of gender on severity of pain is also presented in table 7
In female patient severity of pain did not reduce significantly after 1 day (p=0.239) but it was significantly reduced at 7th day (p=0.008) and 1 month recall (p=0.05). In male patients severity of pain was significantly reduced at 1st day and 1st month (p=0.001).
Effect of location on severity of pain is presented in table 8
Reduction in severity of pain was not statistically significant in Mandibular teeth while severity of pain significantly decreased in maxillary teeth (pre vs. 1 days p=0.006) and (1st day vs. 1st month; p=0.0001).
In endodontic literature the opinion is divided regarding postobturaion pain in single visit root canal treated necrosed teeth as compared to multiple visits RCT. In this clinical study we found that, there were no significant differences in pain experiences in relation to teeth with necrosed pulps. The findings of this study suggest that the incidence of postobturation pain in relation to necrosed teeth was less in single visit RCT. Our results show 92% patients were painless after one month (Table-1). Many researchers are of the opinion that there is no difference in preoperative and postoperative pain in single visit RCT in necrosed teeth as compare to multiple visit RCT. Findings of several studies are in agreement with our findings. The studies of Eleazer and Eleazer 13 and Risso et al.14 established that single visit mode of treatment resulted in less pain in necrosed teeth than those taking two visits. Trope et al.15 and Al-Negrish et al.16 also found that there was no statistically significant difference in the incidence and degree of postoperative pain.
In contrast some studies reported significant postoperative pain after single visit RCT. Peters17 reported that postoperative pain frequency for patients treated in single visit was higher (16%) than patients treated in two appointments (9.6%). Oginni et al.18 compared pain experience in relation to pre-treatment with nonvital pulp established that those with vital pulp had a significant lower frequency of pain (9%) than those with nonvital pulp (41%). Results of our study are in disagreement with the findings of above studies.
Controversy also revolves around the association between existing preoperative and postobturation pain. It is generally hypothesized that postobturation pain is significantly associated with the presence of preoperative pain. The presence of preoperative pain may influence the postobturation pain. Psychologically the patients who visit dentists with pain may expect pain during and after the treatment. Besides this factor, a pathologic factor is also important in these patients. Patients presenting with pain usually have inflamed periapical region. This tissue being initially irritated may become secondarily irritated during treatment. To some authors the presence of preoperative pain was identified as a risk factor for definite postobturation pain.19 In our study similar percentage of patients (table-1) were suffering from preoperative (57%) and post-obturation (58%) pain of mild to severe intensity (table-1) after one day. This finding is in agreement with published literature. In endodontic literature frequency of postobturation pain was positively associated with the presence of preoperative pain. The cumulative flare-up rate of patients with a history of pain (0.420%) was not different than patients with no history of pain (0.32%).9 The Studies of Risso et al.14 and Ince B et al.20 have identified pre-operative pain as a predictor of postoperative flare-ups and are similar to our results. Only a few studies did not find preoperative pain associated with increased incidence of flare-up or severe postoperative pain.21,22,23
Although on the first day recall after obturation there was no difference between preoperative and postoburation pain, this finding is in agreement with the findings of Albashaireh at al21,24 Indeed the results of this study show significant outcome in terms of the severity of pain. Only one patient (1.6%) expressed on and off episodic severe pain after one month (Table-2). Hence findings (98% painless subjects after one month) of this study suggest that single visit root canal treatment in necrosed teeth can prove to be very effective, if performed properly.
Findings in the literature indicate that the age factor bears no significant relationship to the pain experience reported by patients.25 However, some studies show significant association between age and postoperative pain. Cheng et al noted significant differences among different age groups. His findings suggest that the patients over the age of 70 years were more prone to postoperative pain as compared to less than 20 years age group.26 In our study subjects, similar lower post treatment pain responses were found in younger age group in comparison to patients of older age. Our findings match with the findings of Risso et al27 and Albashaireh et al28 and partly match with the findings of Cheng et al.26 who reported less pain in younger age groups.
It is commonly believed that women are more prone than men to develop chronic pain following endodontic treatment.29 In contrast, other studies as mentioned by Polycarpou et al30, Locker & Grushka 198731, MacEntee et al.32 and Risso et al.27 did not find gender differences in prevalence of post operative pain. When the incidence of pain was related to the gender of the patient in our study, it was found that women reported more pain than men. There were 54.83% females with preoperative pain. Postoperative findings show 12.9% with pain and 87% were pain free. Preoperative pain findings in males were observed 59.3%. Only 3% of patients were with postoperative pain and 96.87% were painless after one month. These results support the findings of Cheng et al26 and Watkins et al.33, who have established that the females are more prone to post operative pain.
Association between tooth types and postobturation pain may be more with molar teeth with multiple roots and mandibular segment because of its complex anatomy. The reason may be related to the thicker cortical plate in the mandible that might cause an easy build up of exudate and hence pressure, leading to pain, when compared with the maxilla. The difference between anterior and posterior teeth may be related biologically to a greater number of canals and high frequency of bifurcated root canals in mandibular posterior teeth.29 According to few studies there was a significant difference between maxillary and mandibular teeth with the latter being more likely to suffer from postoperative pain. Mandibular teeth were significantly more susceptible to pain.29,33 In our study no definite association between pain and tooth type could be demonstrated due to small sample size and partly due to single rooted teeth were included in our study. We noticed 55% preoperative pain and 11% postoperative pain in mandibular teeth. The incidence of preoperative pain was 57.7% and postoperative pain 8.8% in maxillary teeth. These findings are in agreement with Risso et al. 27 but at variance with Gesi et al.34
There are variations in study designs, different pain measurement scales, and preoperative conditions of the teeth, different techniques of preparation and obturation, and methods of collecting and analyzing the postobturation pain data, hence comparison between studies of pain is difficult.
A small sample size and lack of a control group are two limitations of our study. Future studies may be designed by keeping these two limitations in mind.
Following conclusions can be drawn from this study.
1. Single visit endodontics result in less post-obturation pain.
2. Single visit endodontics results in less pain in patients of age 16-35, male gander and maxillary teeth..
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