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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 73-77

Comparative assessment of role of intracanal medicaments in pain reduction during endodontic treatment: In vivo: Visual analog scale study


Department of Conservative Dentistry and Endodontics, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Submission05-Apr-2021
Date of Acceptance11-Jul-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Aishwarya Rajesh Mantri
Ratan-Deep, Gokul Vihar, Civil Club Road, Jalna - 431 203, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_83_20

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   Abstract 


Background: The presence of microorganisms as a result of failure to properly disinfect the canal is the most common cause of pain. Thus, the main focus of endodontic therapy is on maximum elimination of these bacteria. Intracanal medicaments have been advocated as inter appointment dressings to eliminate the remaining bacteria after root canal preparation and reduce periapical inflammation of tissues. Aims and Objectives: The aim of this study is to evaluate the effectiveness of calcium hydroxide, triple antibiotic paste and corticosteroid antibiotic paste as an intracanal medicament in pain reduction. Materials and Methods: One hundred and twenty patients with a chief complaint of pain and planned for root canal treatment were randomly selected and were further divided into four groups. Group I (n-30) - control group, Group II (n-30) - receiving calcium hydroxide, Group III (n-30) - receiving triple antibiotic paste and Group IV (n-30) - receiving corticosteroid- antibiotic paste (Ledermix) as an intracanal medicament. Pain was measured using visual analogue scale (VAS). The scores were recorded preoperatively, at 24 hours, 48 hours and 72 hours. The result was tabulated and statistically analysed. Results: At baseline, the mean score pain for all four groups were in the same range. There was no statistically significant difference between the preoperative mean pain score values. Group IV showed the highest pain reduction followed by Group III, Group II and Group I respectively. Conclusions: Under the conditions of this study, painful single rooted teeth that had been dressed with Ledermix paste showed higher pain reduction than the other three groups.

Keywords: Calcium hydroxide, Ledermix, triple antibiotic paste, visual analog scale


How to cite this article:
Daokar SG, Mantri AR, Patil KS, Wahane KD, Rathi SV, Sharma SS. Comparative assessment of role of intracanal medicaments in pain reduction during endodontic treatment: In vivo: Visual analog scale study. J Interdiscip Dentistry 2021;11:73-7

How to cite this URL:
Daokar SG, Mantri AR, Patil KS, Wahane KD, Rathi SV, Sharma SS. Comparative assessment of role of intracanal medicaments in pain reduction during endodontic treatment: In vivo: Visual analog scale study. J Interdiscip Dentistry [serial online] 2021 [cited 2021 Dec 4];11:73-7. Available from: https://www.jidonline.com/text.asp?2021/11/2/73/325114




   Clinical Relevance to Interdisciplinary Dentistry Top


  1. Intracanal medicaments are vividly essential to control the infection and symptoms even after the root canal therapy for better prognosis.
  2. With good long-acting intracanal medication, prognosis of post-endo restoration will be better and it helps in longer clinical success of the cases.



   Introduction Top


The pain of endodontic origin has been a prime concern to the patients and the clinicians.[1] Endodontic treatment is considered successful and readily accepted by the patient when it is painless. Hence, pain management is an important aspect during endodontic treatment.

The presence of microorganisms as a result of failure to properly disinfect the root canal is the most common cause of pain. Thus, the main focus of endodontic therapy is on the complete elimination of the bacteria.[1] The irrigants act for a shorter duration and intracanal medicaments act for a longer duration against microorganisms within the root canal.[2]

To curtail bacterial regrowth and possibly even improve bacterial suppression, an intracanal medication can be advantageous and successfully used to eliminate the bacterial flora. Interappointment antimicrobial medication acts by inhibiting the proliferation of bacteria and further eliminates surviving bacteria as well as minimizes ingress of pathogens through a leaking restoration.[3]

Calcium hydroxide has been widely used in endodontics because of its properties such as high alkalinity and antibacterial activity.[4] However, calcium hydroxide has a limited antibacterial spectrum.[5]

The combination of antibiotics consisting of ciprofloxacin, metronidazole, and minocycline, referred as triple antibiotic paste (TAP) overcomes bacterial resistance and helps in achieving higher antimicrobial action.[6] Minocycline can cause tooth discoloration.[7] Clindamycin has been used as a substitute for minocycline in TAP.[8]

Medicaments that combine antibiotics and corticosteroid elements are highly effective in pain reduction during root canal treatment. The corticosteroid constituent reduces periapical inflammation and gives almost instant relief of pain, whereas the antimicrobial properties are catered by antibiotics.[9]

Hence, the aim of the study is to compare the effect of calcium hydroxide, TAP, and Ledermix paste as intracanal medicaments in pain reduction during endodontic treatment using visual analog scale (VAS).


   Subjects and Methods Top


One hundred and twenty patients in the age group of 16–40 years reporting to the Department of Conservative Dentistry and Endodontics with a chief complaint of emergency pain and willing to undergo endodontic treatment were selected for the trial.

Inclusion criteria

The following quantitative, analytical, and experimental study was confined to single-rooted teeth with a diagnosis of acute and chronic irreversible pulpitis, acute and chronic apical periodontitis, and pulpal necrosis.

Exclusion criteria

Periodontally compromised teeth, teeth with granuloma, cyst, swelling and abscess, teeth with incomplete root formation, and retreatment cases were excluded from the study.

Withdrawal criteria

Noncompliant patients after the first visit were withdrawn from the trial.

Before commencing the treatment, a written consent was obtained from the patient. Root canal treatment was initiated under local anesthesia with rubber dam isolation. Working length was established 1 mm short of the radiographic apex. The coronal one-third of the canal was enlarged using Gates Glidden. The apical portion of the canal was enlarged using K-files to size 3–4 files larger than the initial apical file, and the rest of the canal was prepared using step-back technique. The canals were irrigated copiously with 2.5% sodium hypochlorite and 17% Ethylenediaminetetraacetic acid (EDTA). The normal saline was used between sodium hypochlorite and EDTA for a more efficient action of the chemicals on the tissues. Following instrumentation and irrigation, canals were dried and medicated with one of the following medicaments:

  • Group I (n = 30): No intracanal medicament was placed. A dry cotton pellet was placed (control group), and the access opening was sealed using cavit
  • Group II (n = 30): Calcium hydroxide paste was gently placed into the canal. Excess was removed with cotton swab, and cavity was sealed with cavit
  • Group III (n = 30): TAP was prepared by removing the coating and crushing of ciprofloxacin, metronidazole, and clindamycin tablets separately using mortar and pestle. A total of 100 mg of this triple antibiotic mixture was dispensed and mixed with a drop of propylene glycol to get a thick paste-like consistency. This paste was gently compacted into the canal and access opening was sealed with cavit
  • Group IV (n = 30): Ledermix paste was inserted into the root canal and the access was sealed with cavit.


The first patient did not receive any intracanal medicament (Group I). The second patient received calcium hydroxide (Group II), the third patient received TAP (Group III), and the fourth patient received corticosteroid-antibiotic paste (Group IV) as an intracanal medicament. A dry cotton pellet was placed in the fifth patient, and the cycle was repeated as stated above.

The pain was measured using a VAS. The ratings were done preoperatively, at 24 h, 48 h, and 72 h postintracanal medication. No oral medications were prescribed to the patient postoperatively.

Visual analog pain scale rating

  • 0–25: No pain to mild pain requiring no analgesic medication (score 1)
  • 25–50: Moderate pain requiring analgesic for relief (score 2)
  • 50–75: Severe pain, pain not relieved by above medicaments (score 3)
  • 75–100: Extreme pain, pain not relieved by any measure taken (score 4).



   Results Top


A total of 136 patients were treated, out of which 16 were excluded from the study. Nine patients did not return for further treatment, five of them did not continue their treatment because of financial considerations, and two of them got their tooth extracted because of unbearable pain.

Data were evaluated using SPSS- Statistical Package for the Social Sciences (IBM Corp., Armonk N.Y., USA) software. Analysis of variance test was used to determine the statistical significance at a 95% confidence level within a group and in between the groups. The level of statistically significant difference was accepted at P < 0.05.

The experimental groups showed a higher pain reduction with time in comparison with the control group. This states that the intracanal medicaments are effective in reducing pain during endodontic treatment. There was a statistically significant difference in pain reduction among the three experimental groups.

[Table 1] gives the mean pain score values for each group at different time intervals. At baseline, mean values of each group were in the same range. There was no statistically significant difference in preoperative pain score values of the four groups.
Table 1: Pain scores

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[Table 2] shows that the difference between the mean pain score preoperatively and at 72 h was statistically significant for Group I and Group II. There was no statistically significant difference at preoperative to 24 h interval as well as at 48–72 h interval for Group III. The mean difference of VAS score at 24 h was statistically significant with preoperative, 48 h, and 72 h-time interval in Group IV. Furthermore, the mean difference of VAS score at 48 h was statistically significant with VAS score at 72 h (0.800) in Group IV.
Table 2: Comparison of pain within the groups at different times

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[Table 3] shows that Group IV showed a higher pain reduction with time followed by Group III, Group II, and Group I, respectively.
Table 3: Comparison of pain between the groups at different times

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   Discussion Top


The study was double blinded, in which participants and data analysts were blinded in this trial. The operator could not be blinded due to the nature of the study as the intracanal medicament must be exposed and cannot be masked.

Pain is inherently subjective and its measurements primarily rely on the verbal report of the patients. VAS is considered to be a simple, valid, and reliable scale for the measurement of pain.[6] VAS is usually presented as a 100-mm horizontal line on which the patient's pain intensity is represented by a point between the extremes of “no pain at all” and “worst pain.”[10]

The scores of VAS were categorized ranging from 1 to 4 as mild (score 1), moderate (score2), severe (score3), and extreme (score 4) pain. This was done to make the patient understand the pain scale better quantitatively and accurately.[8]

The numerous past studies show the diminution or absence of interappointment pain when Ledermix was used after debridement.[11]

Ehrmann et al.[12] study results showed the rapidity of the action of intracanal medicament containing corticosteroids. Negm[13] supported the intracanal use of corticosteroid-antibiotic combination for controlling posttreatment endodontic pain.

The corticosteroid constituent reduces periapical inflammation and gives almost instant relief of pain and reduces inflammation of the periapical region of the patient who complains of extreme tenderness to percussion after the canal instrumentation and the antimicrobial properties are catered by antibiotics.[9]

Seltzer criticized the use of corticosteroids in endodontic therapy by stating that the disadvantage of using corticosteroids derives from the effects on inflammatory cells. According to him, inflammatory cells hamper the process of phagocytosis and protein synthesis, which may result in delayed healing. However, Abbott disproved these findings and went to say that even if corticosteroids cause some adverse effects, they are of minor degree, therefore insignificant.[14]

Despite the existing controversy, a large number of clinicians have experienced such dramatic success in using steroids to resolve the clinical manifestations of acute pulpitis, sensitivity, and apical discomfort that their enthusiasm for these compounds has persisted.[12]

TAP group caused more pain reduction than calcium hydroxide and control group. Prasad et al.[8] have also stated that TAP is more effective in managing interappointment pain than calcium hydroxide. This could be attributed to the combined spectrum of antimicrobial activity and synergetic actions of antibiotics ciprofloxacin, metronidazole, and minocycline found in TAP. Individually, ciprofloxacin has broad-spectrum activity and acts against both gram-positive and gram-negative bacteria by inactivating enzymes and inhibiting cell division. Metronidazole is effective against obligate anaerobes and acts by disrupting bacterial DNA. Minocycline is a broad-spectrum tetracycline antibiotic and acts by inhibiting protein synthesis and inhibiting matrix metalloproteinase enzyme. TAP is said to cause the most severe discoloration of the tooth due to minocycline component.[6]

Hence, in this study, minocycline was replaced by clindamycin. The use of clindamycin may be a promising substitute for minocycline, not only based on its broad antimicrobial spectrum and stain-free properties but also because of its reported in vitro proangiogenic activity.[15]

The concern of the TAP is that it may cause bacterial resistance. To overcome this, disadvantage of TAP, ledermix paste was introduced.[16]

Antimicrobial activity of calcium hydroxide depends on the availability of hydroxyl ions in an aqueous environment.[5] The lethal effect on microorganisms has been attributed to the following mechanisms – damage to the bacterial cytoplasmic membrane, protein denaturation, and/or damage to the DNA, yet it is difficult to establish the main mechanism involved in the death of bacteria.[17]

However, calcium hydroxide has a limited antibacterial spectrum. In addition, physicochemical properties of this substance may limit its effectiveness in disinfecting the entire root canal system after a short-term use.[5]

The results observed are in agreement with the previous study conducted by Jindal et al.,[16] They concluded that Ledermix showed better results compared to TAP followed by calcium hydroxide paste during multivisit root canal treatment in decreasing the interappointment pain.


   Conclusion Top


Ledermix paste as an intracanal medicament was more effective in pain reduction followed by TAP and calcium hydroxide during multivisit root canal treatment. As this study has a limited observational period, further studies are to be conducted with extended observational periods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Anjaneyulu K, Nivedhitha MS. Influence of calcium hydroxide on the post-treatment pain in Endodontics: A systematic review. J Conserv Dent 2014;17:200-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ambikathanaya UK. Intracanal antiseptic medications; A review. Unique J Med Dent Sci 2014;02:136-142.  Back to cited text no. 2
    
3.
Neelakantan P, Sanjeev K, Subbarao CV. Duration-dependent susceptibility of endodontic pathogens to calcium hydroxide and chlorhexidene gel used as intracanal medicament: An in vitro evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e138-41.  Back to cited text no. 3
    
4.
Fava LR. Acute apical periodontitis: Incidence of post-operative pain using two different root canal dressings. Int Endod J 1998;31:343-7.  Back to cited text no. 4
    
5.
Siqueira JF Jr, Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361-9.  Back to cited text no. 5
    
6.
Pai S, Vivekananda Pai AR, Thomas MS, Bhat V. Effect of calcium hydroxide and triple antibiotic paste as intracanal medicaments on the incidence of inter-appointment flare-up in diabetic patients: An in vivo study. J Conserv Dent 2014;17:208-11.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Kumar A, Tamanna S, Iftekhar H. Intracanal medicaments–Their use in modern endodontics: A narrative review. J Oral Res Rev 2019;11:94.  Back to cited text no. 7
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8.
Prasad LK, Tanwar BS, Kumar KN. Comparison of calcium hydroxide and triple antibiotic paste as intracanal medicament in emergency pain reduction: In vivo study. Int J Care Res 2016;4:244-6.  Back to cited text no. 8
    
9.
Kundabala M, Jagadish S, Ramya S. Efficacy of Ledermix as a root canal medicament in symptomatic teeth: A clinical study. J Interdiscipl Dent 2014;4:85-8.  Back to cited text no. 9
    
10.
Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y. The visual analog scale for pain: Clinical significance in postoperative patients. Anesthesiology 2001;95:1356-61.  Back to cited text no. 10
    
11.
Memon NA, Memon MR, Ali F. Assessment of the interappointment pain by using two different intracanal medicaments. Pakistan Oral Dent J 2013;33:145-15.  Back to cited text no. 11
    
12.
Ehrmann EH, Messer HH, Adams GG. The relationship of intracanal medicaments to postoperative pain in endodontics. Int Endod J 2003;36:868-75.  Back to cited text no. 12
    
13.
Negm MM. Intracanal use of a corticosteroid-antibiotic compound for the management of posttreatment endodontic pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:435-9.  Back to cited text no. 13
    
14.
Dall AQ, Jouhar R, Ahmed NA. Comparison of Inter-appointment Pain between Ledermix and no intracanal medicament in acute apical periodontitis. J Liaquat Univ Med Health Sci 2011;10:106-1.  Back to cited text no. 14
    
15.
Karczewski A, Feitosa SA, Hamer EI, Pankajakshan D, Gregory RL, Spolnik KJ, et al. Clindamycin-modified triple antibiotic nanofibers: A stain-free antimicrobial intracanal drug delivery system. J Endod 2018;44:155-62.  Back to cited text no. 15
    
16.
Jindal V, Monga S, Jindal D. Comparative evaluation of the interappointment pain by using different intracanal medicaments–An in vivo study. Dent J Adv Stud 2019;7:019-22.  Back to cited text no. 16
    
17.
Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: A literature review-Part I. In vitro studies. Restor Dent Endod 2014;39:241-52.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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