|Year : 2023 | Volume
| Issue : 1 | Page : 23-28
Comparative evaluation of pretreatment and postoperative pain of Curcuma longa extract, grape seed extract with calcium hydroxide as intracanal medicament in symptomatic irreversible pulpitis: An in vivo pilot study
S Arun Kumar1, Brindhu Murugan2, Dhanya Rajan3, Premkumar Elavarasu1, Gayathri Kumar4
1 Department of Conservative Dentistry and Endodontics, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry, India
2 Private Practitioner, Madurai, Tamil Nadu, India
3 Dental Surgeon, West Hempstead, New York, USA
4 Department of Peridontics, SRM Kattankulathur Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||05-Sep-2022|
|Date of Acceptance||20-Mar-2023|
|Date of Web Publication||28-Apr-2023|
Dr. S Arun Kumar
Mahatma Gandhi Institute of Dental Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: The aim of this study was to evaluate pretreatment pain and postoperative pain of Curcuma longa extract, grape seed extract with calcium hydroxide (CaOH2) as intracanal medicament in symptomatic irreversible pulpitis. Materials and Methods: Eighty patients with irreversible pulpitis, between 18 and 60 years were included in the study. After obtaining initial pain scores, patients were randomly allocated to three groups. In first visit, patients were given visual analog scale form to mark pain intensity at start of the treatment and posttreatment. The compiled data collected were statistically analyzed using 20 SPSS software. Results: In all the three groups, for patients undergoing root canal treatment, pain intensity was highest on 1st day of treatment and dropped afterward. A comparison of pain between curcumin and grape seed extract revealed no significant difference in pain scores for the respective time intervals. Intergroup comparison between curcumin and CaOH2 group showed less postoperative pain in C. longa than CaOH2 group. Conclusion: According to the results of this study, Curcumin longa extract has least pain when compared with CaOH2 and grape seed extract when it is used as intracanal medication in symptomatic irreversible pulpitis.
Keywords: Calcium hydroxide, Curcuma longa extract, grape seed extract, intracanal medicament, postoperative pain, pretreatment pain, symptomatic irreversible
|How to cite this article:|
Kumar S A, Murugan B, Rajan D, Elavarasu P, Kumar G. Comparative evaluation of pretreatment and postoperative pain of Curcuma longa extract, grape seed extract with calcium hydroxide as intracanal medicament in symptomatic irreversible pulpitis: An in vivo pilot study. J Interdiscip Dentistry 2023;13:23-8
|How to cite this URL:|
Kumar S A, Murugan B, Rajan D, Elavarasu P, Kumar G. Comparative evaluation of pretreatment and postoperative pain of Curcuma longa extract, grape seed extract with calcium hydroxide as intracanal medicament in symptomatic irreversible pulpitis: An in vivo pilot study. J Interdiscip Dentistry [serial online] 2023 [cited 2023 Jun 6];13:23-8. Available from: https://www.jidonline.com/text.asp?2023/13/1/23/375283
| Clinical Relevance to Interdisciplinary Dentistry|| |
This study was novel by coparing both pretreatment and post treatment pain in symptomatic pulpits patients and also used Herbal products they are Lowers Risk Of Side Effects Cost Effective, Readily Available, Treats Chronic Conditions.
| Introduction|| |
The purpose of nonsurgical endodontic therapy is to eliminate pathogenic microorganisms from the root canal system, shape the canal system, and obturate it with an appropriate material. Root canal infection may still persevere even after rigorous procedures, due to the complexity of the canal system, which is tough to the instrument. As a result, using intracanal medications in such circumstances eliminates infections that persist even after cleaning and shaping, creating an environment favorable for periapical tissue restoration. The absence of clinical signs and symptoms, as well as radiographic evidence of periapical healing, is an indicator of successful root canal treatment (RCT).
Numerous chemicals have been tried as intracanal medicaments. The majority of these preparations excluding calcium hydroxide (CaOH2) are not used regularly in contemporary endodontic practice due to stated toxicity, allergic reactions, and resistance. The growing number of antibiotic-resistant bacteria, as well as the adverse effects of synthetic medications, has prompted experts to hunt for natural alternatives.
Grape seed extract (Vitis vinifera) is well-known in India for more than 2000 years as one of the most versatile medicinal plants having a wide spectrum of biological activity. It is excessively used in Ayurvedic, Unani, and Homeopathic medicine. V. vinifera has been investigated in the control of many diseases, but its real efficacy is still not well clarified scientifically. Results of various studies shows that the extract from V. vinifera is a powerful inhibiting agent against the increase and the establishment of microorganisms that cause infectious diseases in the oral cavity.
Grape seed extract is neither toxic nor does it have any mutageni properties. Besides containing long-known bactericidal traits, it also seems to have anti-inflammatory, astringent, antiseptic, anti-ulcer, antiviral, antihyperglycemia, and immunostimulant properties. Because of the various advantages of grape seed extract, it may be tried as an alternative intracanal medicament to CaOH2 and chlorhexidine (CHX).
According to Whiting et al., turmeric (Curcuma longa) is a traditional herbal medication that is used to cure a variety of ailments. Curcumin (diferuloylmethane), the major yellow bioactive component of turmeric, has been demonstrated to have a wide range of biological functions, including antibacterial, anti-inflammatory, and antioxidant properties.
The present study was carried out to compare and evaluate the pretreatment pain and postoperative pain using C. longa and grape seed extract with CaOH2 as intracanal medicament in symptomatic irreversible pulpitis.
The null hypothesis was that there is no significant difference in pretreatment and postoperative pain.
| Materials and Methods|| |
Eighty patients participated in the controlled clinical trial that was approved by the Institutional Ethical Committee. Participants were selected consecutively from patients referred to the Department of Conservative Dentistry and Endodontics. All were fully informed about the investigation and their written consent to participate was received.
Patients were selected based on the following criteria:
Inclusion criteria as follows
- 18–45 years of age
- Posterior teeth
- Symptomatic irreversible pulpitis
- Pain score ranging from moderate to severe (4–10) on a visual analog scale (VAS) (0–10)
- Informed consent obtained.
Exclusion criteria as follows
- <18 years and >45 years
- Patients taking analgesic and antibiotics <12 h
- Pregnant women
- Calcified canals
- Nonvital teeth.
Clinical trial has been registered with scientific review board. After explanation of the treatment procedures, each patient was anesthetized with 2 ml of xylocaine 2% with adrenaline 1:200,000, AstraZeneca, India, followed by rubber dam isolation and access cavity preparation. Working length was determined with Root ZX Mini Apex Locator (J. Morita, USA) and periapical radiographs. Cleaning and shaping was done using passive step-back technique to enlarge the canal to a minimum apical size of #30 file or larger depending on the size of the canal.
Group 1 – CaOH2
Group 2 – Curcumin longa extract
Group 3 – Grape seed extract
Group 4 – saline (positive control).
Each patient was provided with a preoperative and postoperative pain questionnaire having VAS and side effect chart. Patients were encouraged to make immediate postoperative pain measurement (0 h) to ensure patient understanding of the pain questionnaire. Patients were instructed to complete the questionnaire at 24 h after completion of RCT. Pain intensity was recorded using VAS, which consisted of a 10 cm line anchored by two extremes, “no pain” and “pain as bad as it could be.” Patients were asked to make a mark on the line that represented their level of perceived pain.
| Results|| |
- Descriptive analysis was performed
- Wilcoxon signed-rank test: To assess the difference between the pre- and post-treatment VAS scores within the treatment groups
- Kruskal–Wallis test: To compare the difference in the pre- and post-treatment VAS scores between the treatment groups.
[Table 1] depicts the VAS scores among various groups pre- and post-treatment. The mean VAS score was recorded pre- and post-treatment among the study subjects in all the groups. The highest mean VAS pretreatment was recorded in study subjects belonging to Group 4 (7.90 ± 0.87). However, the highest mean VAS posttreatment was recorded in study subjects belonging to Group 1 (3.70 ± 0.67).
[Table 2] depicts the comparison of mean visual analog scores (VASs) pre- and post-treatment within the treatment groups. The difference in mean VAS score between pre- and post-treatment was the highest for Group 4 (5.40 ± 1.07), followed by Group 3 (5.00 ± 1.15), Group 2 (4.20 ± 0.91), and the least reduction was found in the Group 1 (3.90 ± 1.28). However, the differences between the VAS score pre- and post-treatment in all the groups were highly significant (P < 0.05) indicating a significant pain reduction across all the four groups.
|Table 2: Comparison of mean visual analog scores pre- and post-treatment within the treatment groups|
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[Table 3] depicts the Comparison of pre- and post-treatment mean visual analog scores (VASs) among the treatment groups. The highest mean VAS pretreatment was recorded in study subjects belonging to Group 4 (7.90 ± 0.87) when compared to the other three groups. However, there was no significant difference in the pretreatment VAS scores across the four groups. The highest mean VAS posttreatment was recorded in study subjects belonging to Group 1 (3.70 ± 0.67) indicating the least reduction in pain when compared to the other three groups. The difference between the posttreatment VAS scores across the four groups was statistically highly significant.
|Table 3: Comparison of pre- and post-treatment mean visual analog scores among the treatment groups|
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Pretreatment pair-wise comparisons were not made because Kruskal–Wallis test did show any statistically significant difference between the pretreatment VAS scores of the groups.
[Table 4] depicts the pair-wise comparisons of mean visual analog scores (VASs) between the treatment groups post treatment. The difference between the posttreatment VAS scores of Group 1 versus 2 and Group 3 versus 4 showed no significant difference. This indicates that there is no significant difference in the effect of these groups on posttreatment pain.
|Table 4: Pair-wise comparisons of mean visual analog scores between the treatment groups posttreatment|
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There were significant differences in the posttreatment VAS of Group 1 versus 3 and Group 1 versus 4. Group 3 and 4 had lesser VAS score posttreatment indicating a superior effect on pain reduction when compared to Group 1. Similarly, Group 2 versus 3 and Group 2 versus 4 showed a significant difference in the VAS scores posttreatment. Groups 3 and 4 were significantly superior in their effect to reduce pain posttreatment when compared to Group 2.
[Figure 1] depicts the pretreatment mean visual analog scores (VASs) among the treatment groups. The highest mean VAS pretreatment was recorded in study subjects belonging to Group 4 (7.90 ± 0.87) when compared to the other three groups.
|Figure 1: Mean VASs pretreatment among the treatment groups. VASs = Visual analog scores|
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However, there was no significant difference in the pretreatment VAS scores across the four groups.
[Figure 2] depicts the posttreatment mean visual analog scores (VASs) among the treatment groups. The highest mean VAS posttreatment was recorded in study subjects belonging to Group 1 (3.70 ± 0.67) indicating the least reduction in pain when compared to the other three groups. The difference between the posttreatment VAS scores across the four groups was statistically highly significant.
|Figure 2: Mean VASs posttreatment among the treatment groups. VASs = Visual analog scores|
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[Figure 3] depicts the comparison of mean visual analog scores (VASs) pre and posttreatment within the treatment groups. The difference in mean VAS score between pre- and post-treatment was the highest for Group 4 (5.40 ± 1.07), followed by Group 3 (5.00 ± 1.15), Group 2 (4.20 ± 0.91), and the least reduction was found in the Group 1 (3.90 ± 1.28). However, the differences between the VAS score pre- and post-treatment in all the groups were highly significant (P < 0.05) indicating a significant pain reduction across all the four groups.
|Figure 3: Mean VASs pre- and post-treatment among the treatment groups. VAS = Visual analog scores|
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| Discussion|| |
Endodontic treatment mainly depends on the proper eradication of bacterial growth from the root canal space. The failure of RCT is closely related to the presence of anaerobic, facultative bacteria, and majorly Enterococcus faecalis.
At present, most of the commercial products used as intracanal medicaments are cytotoxic and are not able to completely eliminate bacteria from the dentinal tubules and leading to the usage of biologic medication derived from natural plants. Benefits of utilizing herbal medications are their low cost, low toxicity, easy availability, increased shelf life, and decreased microbial resistance.
In this study, paste form was chosen as it helps ease of placement inside the canal walls. For preoperative and postoperative pain assessment, VAS was used.
Curcuma longa belongs to the family, Zingiberaceae and is commonly known as Turmeric. Curcumin (diferuloylmethane) is the main yellow bioactive component of turmeric and has been shown to have a wide spectrum of actions like anti- inflammatory, antioxidant and antimicrobial activities.
Several clinical studies demonstrated a direct link between pre- and post-operative endodontic pain
levels and also found that treatment of teeth with vital pulp reported significantly higher postendodontic pain compared to teeth with necrotic pulp or retreated teeth.
A recent report suggested that curcumin in aqueous preparations exhibits phototoxic effect against gram positive and gram negative bacteria. In a study by Hemanshi Kumar.
Calcium hydroxide, the gold standard of intracanal medicaments was also taken as a test group. The release of hydroxyl ions in an aqueous environment is responsible for the antimicrobial activity of Calcium hydroxide. Their lethal effects on bacterial cells are probably caused by the mechanisms such as damage to the bacterial cytoplasmic membrane, protein denaturation, and damage to DNA. The endodontic literature provides discouraging information on the antibac- terial effectiveness of Calcium hydroxide against E. faecalis because of the buffering action of dentin.
Several clinical studies demonstrated a direct link between pre- and post-operative endodontic pain levels and also found that treatment of teeth with vital pulp reported significantly higher postendodontic pain compared to teeth with necrotic pulp or retreated teeth. Therefore, we included only vital teeth (irreversible pulpitis) for comparing the postendodontic pain after two-visit root canal therapy. VAS was used for evaluating postoperative pain.
A study by Priyanka et al. showed that CaOH2 with propolis 25% more effective than the mixture of CaOH2 with 2% CHX digluconate as root canal medicament against E. faecalis bacteria. While another study by Love RM et al. postulated that virulence factor of E. faecalis in failed endodontically treated teeth may be related to the ability of E. faecalis cells to maintain the capability to invade dentinal tubules and leads to infection.
A study by Chakravarthy showed that cinnamon extract showed better antimicrobial efficacy against E. faecalis as intracanal medicament as compared to CaOH2, whereas a study by Tennenberg et al. showed Ca(OH)2 had the highest significant cytotoxicity compared to Neem oil.
Researchers have shown that postobturation pain is related to gender. They found a statistically significant difference between the genders and found that more women experienced severe pain as compared to men, at all the three-time intervals of time (12, 24, and 48 h). In this study, a greater number of male patients were there. Hence, the results showing more pain among male patients cannot be considered significant.
CaOH2 is the commercially available and most commonly used intracanal medicament. In this study, it was compared with three other groups, curcumin longa extract which has least pain perception when compared with CaOH2 on other hand when grape seed extract is compared with C. longa extract, curcumin has less pain.
Positive control group saline has least pain when it is compared with other groups.
Further long-term in vivo studies must be conducted with the herbal extracts to know their toxicity and allergic potential and also effectiveness as intracanal medicament.
| Conclusion|| |
According to the results of this study, C. longa extract which is used as an intracanal medicaments showed least postoperative pain when compared with other groups. CaOH2 showed increase in pain perception when compared it with C. longa and grape seed extract. Further research on a larger sample in randomized clinical trial is needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
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